Rca discussion

SECOND EDITION

Core Competencies for Nursing
Leadership and Management

INTRODUCTION TO

QUALITY AND
SAFETY EDUCATION

FOR NURSES

Editors

PATRICIA KELLY
BETH A. VOTTERO
CAROLYN A. CHRISTIE-MCAULIFFE

ISBN 978 ‑0‑8261 ‑2341‑1

11 W. 42nd Street
New York, NY 10036-8002
www.springerpub.com

INTRODUCTION TO
QUALITY AND SAFETY EDUCATION FOR NURSES
Core Competencies for Nursing Leadership and Management, SECOND EDIT ION

Editors
PATRICIA KELLY, MSN, RN
BETH A. VOTTERO, PhD, RN, CNE
CAROLYN A. CHRISTIE-MCAULIFFE, PhD, FNP

The second edition of Introduction to Quality and Safety Education for Nurses has been thoroughly updated with
an emphasis on leadership and management. The content continues to focus on knowledge and skills required
of entry-level nurses in the six Quality and Safety Education for Nurses (QSEN) domains. After heart disease
and cancer, patient safety errors rank as the third-leading cause of death in the United States. As patients’
needs have increased in complexity and inter-professional teamwork and collaboration have become essential,
only strong leadership skills can ensure high-quality and safe care. Nurses, the largest group of healthcare
professionals that spend the most time with patients, are uniquely suited to lead through effective management
and communication in this dynamic environment.

With contributions from nurses, physicians, pharmacists, librarians, attorneys, and other healthcare
professionals throughout the United States and beyond, Introduction to Quality and Safety Education for
Nurses, Second Edition underscores the inter-professional focus grounding healthcare practice today. The
updated edition includes four new chapters on implementing quality and safety initiatives from a leadership
and management perspective, and state-of-the-art information on quality improvement. Each chapter contains
learning objectives, opening scenarios, case studies, interviews, critical thinking exercises, key concepts,
clinical discussion points, review activities, NCLEX-style questions, and web resources.

New to the Second Edition:

• Increased focus on leadership and management aspects of quality and safety
• Updated information from national and state healthcare and nursing organizations
• An evolving clinical case study for application of concepts throughout the text
• Additional patient care cases and real-life examples
• Interviews with a myriad of healthcare professionals such as educators, library scientists, lawyers,

psychologists, risk managers, and many others
• Four new chapters addressing nurse leadership and management of high-quality care, legal and ethical

aspects of quality and safety, delegating patient care and setting priorities, and quality improvement project
management

Key Features:

• Helps nursing schools to fulfill accreditation standards for quality and safety curricula
• Maps the QSEN competencies for knowledge, skills, and attitudes (KSAs) for each chapter
• Includes objectives, critical thinking exercises, case studies, interviews, NCLEX-style questions, photos,

tables, suggested readings, and more in each chapter
• Provides instructor package with PowerPoint slides, Q&A, answers for case study and critical thinking

exercises, and more
• Provides knowledge for nursing education QSEN-specific courses
• KSAs throughout chapters

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Kelly_9780826123411_mech.indd 1 6/19/18 9:39 AM

INTRODUCTION TO
QUALITY AND SAFETY
EDUCATION FOR NURSES

Patricia Kelly, MSN, RN, earned her diploma in nursing from
St. Margaret Hospital School of Nursing, Hammond, Indiana;
baccalaureate in nursing from DePaul University in Chicago, Illinois;
and master’s degree in nursing from Loyola University in Chicago,
Illinois. She is Professor Emeritus, Purdue University Northwest,
Hammond, Indiana. She has worked as a staff nurse, travel nurse,
school nurse, and nurse educator. Patricia has traveled extensively in
the United States, Canada, and Puerto Rico, teaching at conferences

for the Joint Commission, Resource Applications, Pediatric Concepts, and Kaplan,
Inc. She currently teaches nationwide National Council Licensure Examination for
Registered Nurses® (NCLEX-RN®) review courses for Evolve Testing & Remediation/
Health Education Systems, Inc. (HESI), Houston, Texas. She also currently volunteers
in a level one trauma center, emergency room, Advocate Christ Medical Center, Oak
Lawn, Illinois and has been a nursing volunteer at the Old Irving Park Community
Clinic in Chicago, a free clinic for patients without healthcare insurance.

Patricia was director of quality improvement at the University of Chicago
Hospitals and Clinics. She has taught at Wesley-Passavant School of Nursing and
Chicago State University. Patricia was program director of the Associate Degree
Nursing Program and is Professor Emeritus, Purdue University Northwest, College
of Nursing, Hammond, Indiana. Patricia has taught Fundamentals of Nursing, Adult
Nursing, Nursing Leadership and Management, Nursing Issues, Nursing Trends,
Quality Improvement, and Legal Aspects of Nursing. She has been a member of Sigma
Theta Tau, the American Nurses Association, and the Emergency Nurses Association.
She is listed in Who’s Who in American Nursing, Notable American Women, and the
International Who’s Who of Professional and Business Women.

Patricia has served on the board of directors of Tri-City Mental Health Center,
St. Anthony’s Home, and the Mosby Quality Connection. She is a coeditor/author
of Introduction to Quality and Safety Education for Nurses, Core Competencies, first edi-
tion, with coeditors/authors Beth A. Vottero and Carolyn Christie-McAuliffe. Patricia
is also an editor/author of Nursing Leadership and Management, now in its third edi-
tion in the United States and Canada; Essentials of Nursing Leadership and Management
(with Janice Tazbir, coeditor/author), now in its third edition; and Nursing Delegation,
Setting Priorities, and Making Patient Care Assignments (with Maureen Marthaler, coedi-
tor/author), second edition. She contributed a chapter, “Preparing the Undergraduate
Student and Faculty to Use Quality Improvement in Practice,” in Improving Quality,
second edition, by Claire Gavin Meisenheimer. Patricia also contributed a chapter on
Obstructive Lung Disease: Nursing Management in Contemporary Medical-Surgical
Nursing by Rick Daniels. She has served as a national disaster volunteer for the American
Red Cross and has also been a team member on healthcare relief trips to Nicaragua.
Patricia has been a nurse for 50 years and currently lives in Chicago, Illinois, and in
Fort Myers, Florida. She can be reached at [email protected]

Beth A. Vottero, PhD, RN, CNE, earned a baccalaureate degree in
liberal studies with a focus in business management from the Uni-
versity of Maine at Presque Isle; a baccalaureate degree in nursing
from Valparaiso University; a master’s degree in nursing from Uni-
versity of Phoenix; and a PhD in nursing education from Capella
University. Previously, Beth taught in the undergraduate nursing at
Purdue University North Central and the graduate nursing program
at Bethel College. Beth currently is an associate professor of nursing

at Purdue University Northwest, teaching courses including Evidence-Based Practice
and Knowledge Translation at the doctoral level and Informatics and courses in the

Nurse Educator program at the graduate level. At the undergraduate level, she teaches
Quality and Safety for Professional Nursing Practice, Informatics, and Evidence-Based
Quality Improvement projects in the Capstone course.

Beth’s background includes over 18 years as a staff and charge nurse. After com-
pleting her doctorate, Beth coordinated and led a successful Magnet redesignation for
Indiana University Health La Porte Hospital in La Porte, Indiana. She brought a desire
to instill quality concepts to academia where she created an undergraduate quality
course at Purdue Northwest focused on quality and safety in healthcare. Beth is a
research associate with the Indiana Center for Evidence-Based Practice in Hammond,
Indiana, a Joanna Briggs Institute (JBI) Collaborating Center. Through this associa-
tion, she has completed systematic reviews on various topics. In collaboration with
Dr. Lisa Hopp, she assisted in developing an Evidence Implementation Workshop
to train nurses in translation science using an evidence-based quality improvement
focus. Beth is a certified Comprehensive Systematic Review Program Trainer with JBI
and conducts weeklong training for healthcare providers nationally.

Beth has published chapters in Hopp and Rittenmeyer’s Introduction to Evidence-Based
Practice: A Practical Guide for Nurses; Bristol and Zerwekh’s Essentials of E-Learning for
Nurse Educators; and has developed case studies for Zerwekh and Zerwekh’s Nursing
Today: Transitions and Trends. She has published several articles on “Teaching Informatics”
(Nurse Educator QSEN Supplement), “Conducting a Root Cause Analysis” (Nursing
Education Perspectives), and “3D Simulation of Complex Health Care Environments” (Clinical
Simulation in Nursing). Beth is an active member of the QSEN Academic Task Force with
multisite studies on quality and safety education for nurses (QSEN) teaching strategies.
As a funded researcher through Purdue University, Beth has studied factors affecting
medication errors in the clinical setting. Beth can be reached at [email protected]

Carolyn A. Christie-McAuliffe, PhD, FNP, obtained her diploma in
nursing from Crouse-Irving Memorial Hospital School of Nursing,
Syracuse, New York; a baccalaureate and master’s degree in nurs-
ing from the State University of New York, Health Science Center at
Syracuse, Syracuse, New York; and a PhD in nursing from Bingham-
ton University, Binghamton, New York. Her clinical experience has
included staff nursing, home healthcare, oncology care, and private
practice. She has functioned as an administrator primarily in clinical

research and taught at the undergraduate and graduate nursing levels at Crouse-Irving
Memorial Hospital School of Nursing, Syracuse, New York; the College of Notre Dame
of Maryland, Baltimore, Maryland; State University of New York (SUNY) Institute of
Technology, Utica, New York; and Keuka College, Keuka Park, New York. She has
implemented multiple evidence-based practice and quality assurance programs and
served as a compliance officer and Institutional Review Board chair at SUNY Institute
of Technology. Carolyn’s research interest and efforts have focused on primary preven-
tion. The majority of her publications and speaking engagements have centered on
topics of research, evidence-based practice, and leadership.

Currently Carolyn provides Integrative Medicine in her private practice in
Syracuse, NY. In addition, she runs a clinic at the Syracuse Rescue Mission where she
serves as a preceptor for undergraduate and graduate nursing students. Carolyn can
be reached at [email protected]

INTRODUCTION TO
QUALITY AND SAFETY
EDUCATION FOR NURSES
CORE COMPETENCIES FOR NURSING
LEADERSHIP AND MANAGEMENT

Second Edition

Patricia Kelly, MSN, RN

Beth A. Vottero, PhD, RN, CNE

Carolyn A. Christie-McAuliffe, PhD, FNP

Copyright © 2018 Springer Publishing Company, LLC

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ISBN: 978-0-8261-2341-1
ebook ISBN: 978-0-8261-2385-5
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Library of Congress Cataloging-in-Publication Data

Names: Kelly, Patricia, 1941–editor. | Vottero, Beth A., editor. |
Christie-McAuliffe, Carolyn A., editor.

Title: Introduction to quality and safety education for nurses : core
competencies for nursing leadership and management / [edited by] Patricia
Kelly, Beth A. Vottero, Carolyn A. Christie-McAuliffe.

Description: Second edition. | New York, NY : Springer Publishing Company,
LLC, [2018] | Includes bibliographical references and index.

Identifiers: LCCN 2018012105| ISBN 9780826123411 | ISBN 9780826123855 (e-book)
Subjects: | MESH: Nursing—standards | Quality of Health Care | Patient

Safety | Safety Management | United States
Classification: LCC RT73 | NLM WY 16 AA1 | DDC 610.73071/1—dc23 LC record available at

https://lccn.loc.gov/2018012105

Contact us to receive discount rates on bulk purchases.
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Printed in the United States of America.

This book is dedicated by Patricia Kelly to her loving Dad and Mom,
Ed and Jean Kelly (Dad was a Safety Engineer at Inland Steel Company);

to her charming, wonderful fiancé, Ron Vana; to her super sisters,
Tessie Kelly Dybel and Kathy Kelly Milch; to her dear aunts and uncles,

Aunt Pat and Uncle Bill Kelly and Aunt Verna and Uncle Archie
Payne; her nephew, John Milch; her nieces, Natalie Dybel Bevil, Melissa
Milch Arredondo, and Stacey Milch Monks; her nephews-in-law, Tracy

Bevil, Peter Arredondo, and Derek Monks; her grandnephew, Brock
Bevil, and her grandniece, Reese Bevil. I love you all!

Beth Vottero would like to thank her support, her rock, and her
hero . . . her ever-patient husband Dino. Thanks also go to her

children Tom (Army Strong), Mitchell (ump extraordinaire), Micah
(King of Games), Michelle (ever-patient educator), and Trisha (the
beautiful mother); to her amazing parents Tom and Judy, Ray and
Dolly; and to her dog Ben, who sat on a chair and stared at her for

hours while she worked. To her super-human coworkers—you know
who you are and how much you motivate me.

Carolyn A. Christie-McAuliffe would like to acknowledge all
the patients she has been graced to know and work with. Her

efforts on this book are dedicated to them: for the trust and honor
they place in her; for the honesty and courage they exhibit; but

most of all, for the privilege to hear, and see, and witness healing
of mind, body, and spirit. For that privilege, she will always
feel a sense of responsibility to do what she can to facilitate

higher levels of safety and quality in healthcare.

CONTENTS

Contributors xi
Foreword xv
Mary A. Dolansky, PhD, RN, FAAN
Ronda G. Hughes, PhD, MHS, RN, CLNC, FAAN
Preface xix
Acknowledgments xxv

UNIT I. INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR
NURSES: CORE COMPETENCIES FOR NURSING LEADERSHIP AND
MANAGEMENT

1. Overview of Patient Safety and Quality of Care 3
Ronda G. Hughes

2. Quality and Safety Education for Nurses 39
Catherine C. Alexander, Gail Armstrong, and Amy J. Barton

3. Nurses as Leaders and Managers for Safe, High-Quality Patient Care 65
Carolyn A. Christie-McAuliffe

4. Quality and Safety in High-Reliability Organizations 89
Patti Ludwig-Beymer

5. Legal and Ethical Aspects of Nursing 131
Theodore M. McGinn

6. Delegation and Setting Priorities for Safe, High-Quality Nursing Care 155
Maureen T. Marthaler

UNIT II. THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS
BY NURSING LEADERS AND MANAGERS

7. Patient-Centered Care 179
Carolyn A. Christie-McAuliffe

Share Introduction to Quality and Safety Education for Nurses: Core Competencies
for Nursing Leadership and Management, Second Edition

x • CONTENTS

8. Interprofessional Teamwork and Collaboration 211
Gerry Altmiller

9. Informatics 243
Beth A. Vottero

10. Basic Literature Search Strategies 277
Kimberly J. Whalen

11. Evidence-Based Practice 305
Beth A. Vottero

12. Patient Safety 339
Christine Rovinski-Wagner and Peter D. Mills

UNIT III. NURSE LEADERSHIP AND MANAGEMENT FOR QUALITY
IMPROVEMENT

13. Essentials of Quality Improvement 375
Anthony L. D’Eramo, Melinda Davis, and Joanne Belviso Puckett

14. Tools of Quality Improvement 417
Anthony L. D’Eramo and Joanne Belviso Puckett

15. Quality Improvement and Project Management 447
Jamie L. Vargo-Warran

16. The Future Role of the Registered Nurse in Patient Safety and Quality 467
Jerry A. Mansfield, Danielle Scheurer, and Kay Burke

17. Transition from Student Nurse to Leadership and Management of
Your Future as a Registered Nurse 501
Jodi L. Boling and Patricia Kelly

Appendix A: Selected Reports of the National Academies of Sciences, Engineering,
and Medicine, Formerly the Institute of Medicine (IOM) 525

Appendix B: Prelicensure Knowledge, Skills, and Attitudes 527
Appendix C: Critical Thinking Extras 537
Glossary 547
Index 559

CONTRIBUTORS

Catherine C. Alexander, DNP, RN VA Quality Scholar, White River
Junction, Vermont, Adjunct Faculty, MGH Institute of Health Professions,
Boston, Massachusetts

Gerry Altmiller, EdD, APRN, ACNS-BC Associate Professor, Director,
QSEN Institute Regional Center at The College of New Jersey, School of
Nursing, Health, and Exercise Sciences, Ewing, New Jersey

Gail Armstrong, PhD, DNP, ACNS-BC, CNE Associate Professor,
University of Colorado College of Nursing, Aurora, Colorado

Amy J. Barton, PhD, RN, FAAN, ANEF Associate Dean for Clinical and
Community Affairs Professor, Daniel and Janet Mordecai Endowed Chair in
Rural Health Nursing, University of Colorado College of Nursing, Aurora,
Colorado

Jodi L. Boling, MSN, RN, CNS Core Faculty, American College of
Education, Indianapolis, Indiana

Kay Burke, MBA, BSN, RN, NE-BC Chief Nursing Information Officer
University of California, San Francisco Health, San Francisco, California

xii • CONTRIBUTORS

Carolyn A. Christie-McAuliffe, PhD, FNP Integrative Practitioners,
Syracuse, New York

Melinda Davis, RN, MSN, CCRN, CNL Clinical Improvement Consultant,
VHA QMS Consultative Division (10E2C3), Office of Quality, Safety and
Value, Antioch, Tennessee

Anthony L. D’Eramo, MSN, RN, CPHQ ISO Consultant, Region 1, VHA
ISO Consultation Division, Office of Quality, Safety, and Value, Coventry,
Rhode Island, Providence VA Medical Center, Providence, Rhode Island

Ronda G. Hughes, PhD, MHS, RN, CLNC, FAAN Director, Center for
Nursing Leadership, Director, Executive Doctorate of Nursing Practice,
Associate Professor, University of South Carolina, School of Nursing,
Columbia, South Carolina

Patricia Kelly, RN, MSN Professor Emerita, Purdue University Northwest,
College of Nursing, Hammond, Indiana, Faculty, Health Education Systems,
Inc. (HESI), Houston, Texas

Patti Ludwig-Beymer, PhD, RN, CTN-A, NEA-BC, CPPS, FAAN Associate
Professor, Purdue University Northwest, College of Nursing, Hammond,
Indiana

Jerry A. Mansfield, PhD, RN, NEA-BC Executive Chief Nursing Officer
and Chief Patient Experience Officer, Medical University of South Carolina,
Charleston, South Carolina

Maureen T. Marthaler, RN, MS Professor Emerita, College of Nursing,
Purdue University Northwest, Hammond, Indiana

CONTRIBUTORS • xiii

Theodore M. McGinn, JD, BBA, CPA Managing Partner Lavelle Law, Ltd.,
Adjunct Professor, The John Marshall Law School, Chicago, Illinois

Peter D. Mills, PhD, MS Director, VA National Center for Patient Safety
Field Office, Veterans Affairs Medical Center, White River Junction, Vermont
and
Adjunct Associate Professor of Psychiatry, The Geisel School of Medicine at
Dartmouth College, Hanover, New Hampshire

Joanne Belviso Puckett, EdM, RN Director, Quality and Risk Management,
USAF 48th Medical Group, Royal Air Force, Lakenheath, United Kingdom

Christine Rovinski-Wagner, MSN, ARNP National Transformational
Coach Captain, VHA Office of Veterans Access to Care, Faculty Scholar, VA
Quality Scholars Fellowship Program, White River Junction, Vermont
and
Clinical Instructor in Community and Family Medicine, The Geisel School of
Medicine at Dartmouth College, Hanover, New Hampshire

Danielle Scheurer, MD, MSCR, SFHM Hospitalist and Chief Quality
Officer, Associate Professor of Medicine, Medical University of South
Carolina, Charleston, South Carolina

Jamie L. Vargo-Warran, DM/IST, MSN, BSN, LSSGB Dean, Academic
Affairs, Chamberlain University College of Nursing, Rancho Cordova,
California

Beth A. Vottero, PhD, RN, CNE Associate Professor of Nursing, Purdue
University Northwest, College of Nursing, Research Associate, Indiana
Center for Evidence-Based Nursing Practice, Joanna Briggs Collaborating
Center, Hammond, Indiana

Kimberly J. Whalen, MLIS Associate Professor of Library Services, Health
Sciences Librarian, Valparaiso University, Valparaiso, Indiana

FOREWORD

Nurses are at the core of healthcare delivery and their role requires both competence
and leadership to ensure that high quality and safe care is provided. It is exciting to
see the publication of the second edition of Quality and Safety Education for Nurses: Core
Competencies for Nursing Leadership and Management. Based on the Quality and Safety
Education for Nurses (QSEN) competencies (Cronenwett et al., 2007) and emphasizing
leadership and management principles, this book is a valuable educational resource
that facilitates teaching contemporary nursing practice. Nursing students and fac-
ulty across the nation will benefit from the content of the book. It includes personal
interviews, essential content, and study questions that promote reflection and criti-
cal thinking. The book is an essential resource to learning and applying the QSEN
competencies.

Now is the time for nurses to have the knowledge, skills, attitudes, and leadership
to provide consistent high quality and safe care. Although there is evidence that we
have made some progress in the delivery of care (National Patient Safety Foundation,
2015) since the Institute of Medicine (IOM) report over 17 years ago (IOM, 2000, 2003),
medical error remains the third leading cause of death (Makary & Daniels, 2016).
This is due in part to the increasing complexity and dynamic nature of healthcare, the
delivery of care by interprofessional teams that demands new types of communica-
tion strategies, and the challenge of integrating informatics and the electronic health
record. The delivery of healthcare is not what it used to be and new educational strate-
gies are needed to address these changes.

The QSEN competencies were developed over 12 years ago and schools of nursing
continue to report that the QSEN competencies are not integrated into their curricu-
lum (Altmiller & Armstrong, 2017). This is concerning as 24% of NCLEX® questions
are directly related to quality and safety content. Since 2012, the QSEN Institute at the
Case Western Reserve University Frances Payne Bolton School of Nursing has contin-
ued the QSEN movement by continuing to provide resources to integrate the QSEN
competencies into the curriculum in the classroom, simulation lab, and clinical experi-
ences. The qsen.org website provides ready-to-use teaching strategies, resources, and
connections to QSEN experts. A monthly newsletter and annual conference connect
nurse educators and nurse practice leaders to ensure that nursing students are quality
and safety practice ready and that nurse preceptors and practicing nurses are ready to
role-model quality and safety standards.

xvi • FOREWORD

The QSEN movement includes a fundamental paradigm shift: a shift from nurses
not just doing their work but improving their work. This requires nurses and other
healthcare professionals to “systems think” and garner the power to change the sys-
tems in which they work (Dolansky & Moore, 2013). Systems thinking moves nurses to
not just have the knowledge and skill to deliver care to their patients (e.g., use the five
steps to safe medication administration) but to understand and value the connections of
their actions to the systems of care around them (e.g., ask how many medication errors
are occurring on my unit and what actions are being taken to reduce these errors). This
paradigm shift to systems thinking requires nurses to embrace a philosophy of con-
tinuous improvement that facilitates learning from errors and designing new ways of
providing care that ensure high quality and safe care.

Professor Emerita Patricia Kelly, Dr. Beth Vottero, and Dr. Carolyn Christie-
McAuliffe bring the QSEN core competencies alive in this introductory book to
improve student preparation. The addition of leadership and management to this
second edition of the book is important as they are important at both the front line
and the management level of patient care. Leadership and management are essential
to move from traditional nursing care to nursing care that includes systems change
to improve patient care. Leadership is the necessary ingredient to empower nurses
to stand-up and speak out and say, “I am not going to do this workaround any lon-
ger as it violates my core value of delivering high quality and safe care.” As Eleanor
Roosevelt said, “With the new day comes new strength and new thoughts.” Let us
embrace these words and move quality and safety to new heights.

Mary A. Dolansky, PhD, RN, FAAN
Associate Professor and Director of the QSEN Institute

Frances Payne Bolton School of Nursing
Case Western Reserve University

Director of Interprofessional Integration and Education
Center of Excellence in Primary Care

VA Quality Scholars Program (VAQS) Senior Nurse Fellow
Louis Stokes Cleveland VA Medical Center

REFERENCES

Altmiller, G., & Armstrong, G. (2017). National QSEN faculty survey results. Nurse Educator,
42(5S), 1–6.

Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P., . . . Warren, J.
(2007). Quality and safety education for nurses. Nursing Outlook, 55(3), 122–131.

Dolansky, M. A., & Moore, S. M. (2013). Quality and safety education in nursing: The key is sys-
tems thinking. Online Journal of Issues in Nursing, 18(3), 1.

Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, DC: National
Academies Press.

Institute of Medicine. (2003). Health professions education: A bridge to quality. Washington, DC: National
Academies Press.

Makary, M. A., & Daniels, M. (2016). Medical error—The third leading cause of death in the US. BMJ,
353, i2139.

National Patient Safety Foundation. (2015). Free from harm: Accelerating patient safety improve-
ment fifteen years after to Err is Human. A report from an expert panel. Retrieved from
http://www.npsf.org/?page=freefromharm#form

FOREWORD

Healthcare providers and consumers of care demand excellence. When that is not
achieved, and less than optimal outcomes are realized, the competence of individual
providers pushes to the forefront of discussions, complaints, and root cause investiga-
tions. Assuming or judging individual competence is complicated, particularly when
other causes, such as organizational factors, are disregarded or not appreciated. In too
many instances, particularly when care does not meet our expectations or an adverse
event occurs, the key factors indicate troubles with the competency of not just one but
many.

With the increasing complexity of healthcare and patient needs, there is a demand
for qualified and competent healthcare providers for high-quality, safe patient care.
The attainment of nursing quality and safety competencies begins during coursework
and clinical preparation, is developed in practice, and is refined with experience. While
we may agree that all healthcare providers need to demonstrate specific competen-
cies in practice, we struggle with the definition, context, attainment, importance, and
demonstration of competencies within various healthcare environments. A common
understanding of the definitions, standards, and domains of competencies is essential
and antecedent to potential associations with understanding and improving organiza-
tional, professional, and patient outcomes.

Each day, nurses fulfill many different expectations in different contexts with
changing demands and multiple challenges. To do so, nurses apply and adapt their
competencies as part of their professional practice performance. The application and
adaptation of one’s competencies are influenced by many factors, including attitudes,
motives, and perceptions. Notwithstanding, perceptions of functioning competencies
or levels of competencies may be intertwined with the performance of other nurses
and healthcare providers. As such, there are challenges in measuring competencies
and understanding the confluence of competencies across healthcare teams. It may be
that differences in scope of practice among the professions do not necessarily indicate
discipline-specific competencies. Instead, competencies are interdependent and prac-
tice specific.

Core competencies for quality and patient safety have been defined by the Quality
and Safety Education for Nurses (QSEN) initiative, funded by the Robert Wood Johnson
Foundation, to prepare the future nursing workforce with necessary knowledge, skills,
and attitudes to be actively engaged in improving the quality and safety of health-
care. The approach in this book is based on QSEN and is structured to ensure that

xviii • FOREWORD

students will obtain the recommended competencies and knowledge necessary to provide
care that is both high quality and safe in practice. Patricia Kelly, Beth A. Vottero, and Carolyn
A. Christie-McAuliffe bring the QSEN core competencies together with leadership and
management in an introductory book to improve student preparation. It is a book that will
be an essential tool on our journey to realize the quality and safety of care we all demand.

Ronda G. Hughes, PhD, MHS, RN, CLNC, FAAN
Associate Professor/Director, Center for Nursing Leadership

College of Nursing, University of South Carolina
Member, Institute of Medicine Committee on Credentialing Research in Nursing

Editor, Patient Safety and Quality: An Evidence-Based Handbook for Nurses
Agency for Healthcare Research and Quality

PREFACE

The 1994 Institute of Medicine (IOM) report, America’s Health in Transition: Protecting and
Improving Quality, highlighted the seriousness and pervasiveness of healthcare error rates
and their effect on patient outcomes and morbidity and mortality rates. Then, in 2000, the
IOM released the report, To Err Is Human: Building a Safer Health System. This IOM report
instantly received national attention from policymakers, healthcare providers, and con-
sumers. The IOM report stated, “At least 44,000 people, and perhaps as many as 98,000
people, die in hospitals each year as a result of medical errors that could have been pre-
vented.” This IOM report caused major ripples throughout the healthcare system and
highlighted the need to change how healthcare is delivered. Shockingly, recent research by
Makary and Daniel (2016) has found that more than 250,000 deaths each year are the result
of errors within healthcare. That means that after heart disease and cancer, patient safety
errors are the third leading cause of death in the United States (Makary & Daniel, 2016).

America has some of the best hospitals in the world but it is also the only large,
rich country without Universal Healthcare coverage. About half of Americans have
their health insurance provided by their employers. Healthcare costs can be financially
ruinous for others. In 2016, America spent $10,348 per person on healthcare, roughly
twice as much as the average for comparably rich countries. On average, both hospital
cost and drug prices can be 60% higher than in Europe. The American Affordable Care
Act expanded the health insurance system and cut the number of uninsured people
from 44 million to 28 million but still left a gap among people not poor enough to
qualify for Medicaid, but not rich enough to buy private insurance.

In the U.S., prices for the same service can vary enormously. Having your appen-
dix removed, for example, can cost anywhere from $1,500 to $183,000 depending
on the insurer. Add to this the fact that 9 of the 10 best-paid occupations in the U.S.
involve medicine, and we see that doctors and other healthcare providers have little
incentive to change the system.

The 2001 release of the IOM report, Crossing the Quality Chasm: A New Health System
for the 21st century, spotlighted general problems in healthcare in an attempt to close the
gap between what is known to provide quality healthcare and what is actually occur-
ring in practice. This IOM report defined six principles for healthcare: Healthcare should
be Safe, Timely, Effective, Efficient, Equitable, and Patient-Centered (STEEEP Principles).
This IOM report also identified 10 rules for care delivery redesign (available at www.nap.
edu/catalog/10027/crossing-the-quality-chasm-a-new-health-system-for-the). This IOM
report spawned a series of other IOM reports on priority healthcare areas, for example,

xx • PREFACE

public health; biomedical and health research; diseases; quality and patient safety; health
services, coverage, and access; select populations and health disparities; food and
nutrition; veterans’ health; healthcare workforce; environmental health; global health;
substance abuse and mental health; women’s health; aging; and education.

The IOM report, The Future of Nursing: Leading Change, Advancing Health (2011), recom-
mended that nurses practice to the full extent of their education, improve nursing edu-
cation, provide nursing leadership positions in healthcare redesign, and improve data
collection for workplace planning and policy making. This IOM report further states that
strong leadership is critical if the vision of a transformed healthcare system is to be realized.
The nursing profession must produce leaders throughout the healthcare system. Everyone
from the bedside to the boardroom must engage colleagues, subordinates, and executives
so that together they can identify and achieve common goals (Bradford & Cohen, 1998).
Nurses must understand that their leadership is as important to providing quality care as
is their technical ability to deliver care at the bedside in a safe and effective manner.

Care has been provided to patients from early history, often by religious orders.
More recently, Florence Nightingale led 38 women into Scutari Barrack Hospital in
Turkey in 1854 to manage care for British casualties of the Crimean War. She went on
to establish Saint Thomas Hospital and the Nightingale Training School for Nurses in
1860. Many other nurses have also led and managed patient care; some of them hon-
ored in the American Nurses Association Hall of Fame (see www.nursingworld.org/
Hall-of-Fame for a listing of ANA Hall of Fame inductees).

Every nurse is a nursing leader and manager, from the beginning frontline nurse
who works directly with patients and takes action to ensure their safety and care quality
to the advanced practice nurse clinician to the top federal nurse administrator in health
services, scientific and academic organizations, and public health and community-based
organizations. All of these nurses continuously demonstrate leadership and management
and work with the interprofessional team to ensure patient-centered, high quality, safe,
evidence-based care, utilizing informatics as appropriate.

The IOM reports also called for changes in how healthcare organizations provide
safe, high-quality patient care services. Currently, the IOM and many others, includ-
ing clinicians, healthcare organizations, employers, consumers, foundations, research
agencies, government agencies, and quality organizations are working to create a more
patient-centered, 21st-century healthcare system.

A primary movement for change in nursing academia toward the inclusion of more
educational information on STEEEP Principles has been the Quality and Safety Education
for Nurses (QSEN) initiative. QSEN followed the IOM lead and stated that changes in
healthcare needed to focus on the development of nursing competencies in patient-cen-
tered care, teamwork and collaboration, quality improvement, evidence-based practice,
and informatics. Because of nurses’ unique position at the sharp end, front line of care in
direct contact with patients, safety was added as a sixth QSEN competency. The QSEN
initiative convened a national panel of experts to identify the core knowledge, skills, and
attitudes (KSAs) required for each of the six competencies. Information about the KSAs
is available at qsen.org. QSEN also sponsors nursing conferences including:

• An annual QSEN Forum to attract nursing leaders in academia and practice to
share innovations and research in patient quality and safety.

• An annual Summit on Leadership and Quality Improvement to explore interprofes-
sional and frontline leadership strategies that will help to accelerate organizational
and systems cost, safety, and quality improvement performance in organizations
(qsen.org/conferences/1st-annual-summit-on-leadership-and-quality-improvement-
accelerating-change-through-positive-forms-of-leadership/).

PREFACE • xxi

Another significant movement for healthcare change comes from the Agency for
Healthcare Research and Quality (AHRQ). This agency, with funding from the Robert
Wood Johnson Foundation, published Patient Safety and Quality: An Evidence-Based
Handbook for Nurses (2008), edited by Ronda G. Hughes, to provide all nurses with evi-
dence-based techniques and interventions to improve patient outcomes. AHRQ also
provides many other resources for Quality and Patient Safety at their website.

WHY THIS BOOK, QUALITY AND SAFETY EDUCATION
FOR NURSES: CORE COMPETENCIES FOR NURSING
LEADERSHIP AND MANAGEMENT, SECOND EDITION?

The idea for this book was born when two of the editors, Patricia Kelly and Dr. Beth A.
Vottero attended the 2011 QSEN conference in Milwaukee, Wisconsin. Patricia and Beth,
both from the Chicago area, invited Dr. Carolyn A. Christie-McAuliffe, from New York,
to join them as the third editor to facilitate the development of a broad look at quality and
safety. The three coeditors experienced the rapid evolution of quality and safety infor-
mation in their clinical and academic practices and they identified the need for nursing
students to receive an understanding of quality and safety in their basic nursing prepa-
ration. The three editors believed in the need to organize existing information about
quality and safety into one basic, easily understood textbook. This need was recently
emphasized with the publication of the Makary and Daniel report (2016), mentioned
earlier. This report is shocking to us as nurses who have been delivering what we believe
is safe high-quality nursing care for a combined total from the three editors of approxi-
mately 112 years! The purpose of this book is to provide a comprehensive overview of
the essential QSEN KSAs about the six quality and safety competencies in nursing prac-
tice to beginning frontline leaders and managers of interprofessional patient care. These
frontline nursing leaders and managers use informatics and work with interprofessional
teams to deliver patient-centered, evidence-based, safe, high-quality patient care.

Many practical examples from real-life experiences are discussed in this text for stu-
dents. The contributors to this text include nurse educators, nurse faculty, nurse researchers,
library scientists, nurse administrators, nurse case managers, physicians, lawyers, nurse
quality improvement practitioners, nurse practitioners, nurse entrepreneurs, psychologists,
and others. The contributors are from all over the United States, emphasizing a broad view
of quality and safety. There are U.S. contributors from Colorado, Florida, Illinois, Indiana,
New Hampshire, New Jersey, Massachusetts, New York, Ohio, Pennsylvania, Rhode Island,
South Carolina, Vermont, and Washington, DC, as well as an international contributor.

Each chapter includes interviews with experts in their respective healthcare field
to provide an interprofessional team perspective. Interviewees include pharmacists,
nurses, lawyers, physicians, library scientists, quality improvement nurses, radiol-
ogy technologists, nurse practitioners, hospital board members, members from the
Committee of Directors for Joanna Briggs Institute, patients, and others.

An important feature of this book is the listing of QSEN competencies and the
associated KSAs found in Appendix B. Appendix B also identifies the chapter in which
the QSEN competency’s KSA information can be found in the text. This will help both
students and faculty plan for the development of KSA competency in students.

ORGANIZATION

Quality and Safety Education for Nurses: Core Competencies for Nursing Leadership and Manage-
ment, Second Edition, consists of 17 chapters. Each chapter provides nursing students and

xxii • PREFACE

beginning nurses with a background and foundational knowledge of quality and safety to
assist them in their role as sharp end, frontline leaders in today’s healthcare environment.

• Unit I, “Introduction to Quality and Safety Education for Nurses: Core Competencies
for Nursing Leadership and Management,” includes eight chapters. They are
“Overview of Patient Safety and Quality of Care,” “Quality and Safety Education
for Nurses,” “Nurses as Leaders and Managers for Safe, High-Quality Patient Care,”
“Quality and Safety in High-Reliability Organizations,” “Legal and Ethical Aspects of
Quality and Safety,” “Delegation and Setting Priorities for Safe, High-Quality Nursing
Care,” “Patient-Centered Care,” and “Interprofessional Teamwork and Collaboration.”

• Unit II, “The Use of Quality and Safety Education Concepts by Nursing Leaders
and Managers” includes four chapters. They are “Informatics,” “Basic Literature
Search Strategies,” “Evidence-Based Nursing Practice,” and “Patient Safety.”

• Unit III, “Nurse Leadership and Management for Quality Improvement,” includes
five chapters. They are “Essentials of Quality Improvement,” “Tools of Quality
Improvement,” “Quality Improvement and Project Management,” “The Future Role
of the Registered Nurse in Patient Safety and Quality,” and “Transition from Student
Nurse to Leadership and Management of Your Future as a Registered Nurse.”

CHAPTER FEATURES

Several chapter features are used throughout the text to provide the reader with a con-
sistent format for learning. Chapter features include the following:

• Photos, tables, and figures to enhance student understanding
• Healthcare or nursing quotes and interviews to illustrate the chapter content
• Objectives that state the chapter’s learning goals
• Opening Scenario, a mini entry-level clinical situation that relates to the chapter,

with two or three critical thinking questions
• Key Concepts, a listing of the primary understandings the reader is to take from

the chapter
• Key Terms, a listing of important new terms defined in the chapter and identified

within the chapter by bold type
• Clinical Discussion Points for nurses, several questions to engage students in dia-

logue (guidelines for discussion are available online)
• Review Questions, several multiple-choice and alternate-style National Council

Licensure Examination for Registered Nurses (NCLEX-RN) questions (answers to
Review Questions available online)

• Review Activities, to help students apply chapter content to patient care situations
(answers to Review Activities available online)

• Exploring Websites
• References
• Suggested Readings
• QSEN Activities

Special elements are sprinkled throughout several chapters to enhance student learn-
ing and encourage critical thinking and application of the knowledge presented. These
include the following:

• Highlights of historical nursing leaders and managers, many of them in the
American Nurses Association Hall of Fame

• Evidence From the Literature with a synopsis of key findings from nursing and
healthcare literature

PREFACE • xxiii

• Real-World Interviews with healthcare leaders and managers, including nursing staff,
clinicians, administrators, risk managers, faculty, nurses, physicians, patients, nurs-
ing assistive personnel, lawyers, pharmacists, hospital administrators, and others

• Critical Thinking Exercises regarding a safety- or quality-related issue (answers to
Critical Thinking exercises available to faculty online)

• Case Studies to provide the nursing student with a patient care situation calling
for critical thinking to solve an open-ended problem (answers to Case Study ques-
tions available to faculty online)

• Answers to all questions, opening scenarios, and QSEN activities are available to
faculty online

HIGHLIGHTS OF THE TEXT

New to the Second Edition is a robust online evolving clinical case study as an instruc-
tional supplement for faculty to guide teaching the content, with options for how to
use the case study for student learning. The content includes discussion questions for
each section of the case study or guidance for a written paper assignment. The evolv-
ing case study pulls content from the text into how to address an evidence-based qual-
ity improvement project as a new nurse.

• A strong foundation for evidence-based healthcare with attention to high quality,
safe care is emphasized throughout the text.

• Chapters include new information from national, federal, and state healthcare and
nursing organizations.

• Leadership and management for frontline nurses are highlighted throughout the
text and within each topic.

• Teamwork and interprofessional collaboration is stressed throughout the text.
• The six QSEN competencies with their KSAs are highlighted in the chapters.
• There are many critical thinking activities, case studies, and clinical discussion

points for nurses throughout the chapters.
• There is an additional set of critical thinking exercise in Appendix C (answers are

available to faculty online).

INSTRUCTOR RESOURCES

1. PowerPoint lecture slides for each chapter serve as guides for faculty presenta-
tions in the classroom. These can be obtained for qualified instructors by emailing
Springer Publishing Company.

Patricia Kelly
Beth A. Vottero

Carolyn A. Christie-McAuliffe

REFERENCES

Agency for Healthcare Research and Quality (AHRQ). (2008). Patient safety and quality: An
evidence-based handbook for nurses. AHRQ Publication No. 08–0043. Rockville, MD: Author.
Retrieved from http://www.ahrq.gov/professionals/clinicians-providers/resources/
nursing/resources/nurseshdbk/index.html

Bradford, D. L., & Cohen, A. R. (1998). Power up: Transforming organizations through shared leader-
ship. Hoboken, NJ: John Wiley & Sons.

xxiv • PREFACE

Institute of Medicine (IOM). (1994). America’s health in transition: Protecting and improving qual-
ity. Washington, DC: National Academy of Sciences. Retrieved from http://www.nap.edu/
openbook.php?record_id=9147&page=R1

Institute of Medicine (IOM). (2000). To err is human: Building a safer health system. Washington,
DC: National Academy of Sciences. Retrieved from http://www.nap.edu/openbook.
php?record_id=9728&page=R1

Institute of Medicine (IOM). (2001). Crossing the quality chasm: A new health system for the 21st cen-
tury. Washington, DC: National Academy of Sciences. Retrieved from https://www.nap.
edu/catalog/10027/crossing-the-quality-chasm-a-new-health-system-for-the

Makary, M., & Daniel, M. (2016). Medical error—The third leading cause of death in the U.S.
British Medical Journal, 353, i2139. doi:10.1136/bmj.i2139

Land of the free-for-all: America is a health-care outlier in the developed world. Economist. April
26th 2018, available at, https://www.economist.com/news/special-report/21740871-only-
large-rich-country-without-universal-health-care-america-health-care-outlier.

ACKNOWLEDGMENTS

A book such as this requires much effort and the coordination of many persons.
Pat, Beth, and Carolyn would like to thank all of the contributing authors for
their time and effort in sharing their knowledge gained through years of expe-
rience in both clinical and academic settings. All of the contributing authors on
both editions within tight time frames to share their expertise. Thanks also to Jane
Woodruff for her computer support and Jane A. Walker, PhD, RN, for her net-
working support.

We would like to acknowledge and sincerely thank the Springer Publishing
Company team who worked to make this book a reality. Joseph Morita, senior acqui-
sitions editor, and Chris Teja, assistant editor, are great people who worked hard to
bring the first edition of this book to publication. We would also like to acknowledge
and thank Cindy Yoo, Managing Editor, Nursing, Springer Publishing Company;
Nandhakumar Krishnan, Key Accounts Manager, DiacriTech Technologies; and
Kumeraysen Vaidhyanadhasamy, Project Manager, DiacriTech Technologies, for their
hard work on the second edition.

The three co-editors would like to thank the following nursing, medical, and
librarian authors for their contributions to the First Edition of this book:

Anne Anderson, DNP, MHSA, RN, CPHQ, NEA-BC (Winfield, Illinois)

Pauline Arnold, MSN, MSA, RN, HACP (LaPorte, Indiana)

Esther Bankert, PhD, RN

Lindsay Bonaventura, MS, RN, FNP, BC (Chesterton, Indiana)

Ashley Currier, MSN, RN, NE-BC (Chicago, Illinois)

Mary A. Dolansky, PhD, RN, FAAN (Cleveland, Ohio)

Mary Gillaspy, MLS, MS (Woodland Park, Colorado)

Corinne Haviley, RN, MS, PhD (Winfield, Illinois)

Joanne M. Joseph, PhD

Andrea Lazarek-LaQuay, MS, RN

xxvi • Acknowledgments

Karen L. McCrea, DNP, FNP-C (Washington, DC)

Francia I. Reed, MS, RN, FNP-C (Utica, New York)

Kathleen Fischer Sellers, PhD, RN (Alfred, New York)

Donna L. Silsbee, PhD, RHIA, CTR, CCS (Utica, New York)

J. Scott Thomson, MLIS, AHIP (North Chicago, Illinois)

Cibele C. Webb, MSN Ed., RN (Mishawaka, Indiana)

Patrick M. Webb, MD (LaPorte, Indiana)

Share
Introduction to Quality and Safety Education for Nurses:

Core Competencies for Nursing Leadership and
Management, Second Edition

UNIT I .
INTRODUCTION TO QUALITY AND
SAFETY EDUCATION FOR NURSES:
CORE COMPETENCIES FOR NURSING
LEADERSHIP AND MANAGEMENT

Upon completion of this chapter, the reader should be able to

1. Define quality of care and patient safety.

2. Discuss key terms used to define quality of care and patient safety.

3. Identify national healthcare organizations influencing quality and safety.

4. Discuss measuring quality and safety.

5. Discuss core measures, sentinel events, and never events.

6. Discuss healthcare quality and safety in industrialized countries.

7. Describe the costs of achieving patient safety and quality of care.

8. Describe key programs that recognize hospital excellence.

9. Discuss the influence of the Institute of Medicine’s (IOM) Quality Chasm
series of reports.

10. Discuss the role of nurses at the “sharp” end of healthcare.
11. Discuss efforts to increase healthcare transparency, improve public

reporting of healthcare, and reduce unwarranted variation in healthcare
safety and quality.

1
OVERVIEW OF PATIENT SAFETY AND
QUALITY OF CARE

Ronda G. Hughes

It is, I guess, politically correct, widely believed, that to say that American health care is the best in the
world. It’s not. (Berwick, 2009)

4 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

A
patient, Mr. R., was admitted to the hospital with uncontrollable pain from a kidney
stone. He also had a history of sleep apnea. The nursing unit was short staffed that
night and each nurse was busy, taking care of more patients than normal. Mr. R., who
was a tall, overweight, 46-year-old man, kept asking for additional intravenous pain

medication as he walked around the unit to try to ease the pain. The nurse called the physician to
increase the dose of the pain medication. The physician ordered the increase and the nurse on the
next shift proceeded to administer the higher dose without looking at how much pain medication
Mr. R. had already received in the past 12 hours, nor did the nurse look at his health history. An
hour later, Mr. R. told his nurse that he finally had some pain relief and he was going to his room
to see if he could sleep for a few hours. His nurse, busy with other patients, went to check on
Mr. R. 3 hours later. She found Mr. R. in his bed, cold to the touch with no respirations. He had
been dead for 2 hours by the time the nurse went to check on him. With the combination of what
ended up being too high of a dose of the pain medication (a medication known to be associated
with life-threatening respiratory depression), the patient’s history of sleep apnea, and the fact that
the nurse did not assess her patient during a 3-hour period, the nurse, the physician, and the
hospital were sued for malpractice by the family.

1. What should the nurse have done prior to administering the last dose of the pain
medication?

2. What should the nurse have done after administering the last dose of the pain medication?
3. What should the nurse, physician, and hospital have done to assist the nurse in avoiding

the medication error?

During the past 20 years, our nation has been focused on improving healthcare out-
comes for patients and their families through improving the quality and safety of
care. Concerns about rising healthcare costs, difficulty in accessing care, and health-
care research have highlighted the need for improving healthcare, and national initia-
tives have been implemented to accelerate change. However, improvements in quality
and safety have been slow. These improvements can be slowed by the complexity of
healthcare and the everyday challenges and opportunities of ensuring that the care
available to and accessed by patients and their families reflects high quality and is safe.
This slow improvement in quality and safety could be considered outrageous, espe-
cially considering how much is spent on healthcare in the United States, more than any
other country in the world.

Frontline bedside nurses, as well as all nurses, have a significant leadership role
to play in patient care. They have a significant influence on the incidence of patient
falls, pressure ulcers, nosocomial infections, pain management, quality improvement
(QI), and safety. Nurses influence patient satisfaction, mortality and morbidity rates,
lengths of stay, complications, and so on. When a patient is at risk for a problem, it is
often the bedside nurse who alerts the interprofessional team and begins the problem-
solving process on behalf of patients.

This chapter provides an overview of the key concepts, drivers, and strategies
for improving the quality of care and patient safety. Specifically, it begins with an
overview of key terms used to define quality of care and patient safety, followed by
key factors that influence healthcare safety and quality including the role of national
healthcare accreditation organizations. The chapter then provides an overview of
core measures, sentinel events, and never events. Since healthcare and patient safety
issues are occurring worldwide, the chapter also includes an overview of quality and
safety in industrialized countries. The chapter then provides a discussion of the costs
of achieving patient safety and quality of care, and the key programs that recognize

1 OVERVIEW OF PATIENT SAFETY AND QUALITY OF CARE • 5

hospital excellence. This is followed by an overview of the influence of the Institute
of Medicine’s (IOM) Quality Chasm series of reports and how the role of nurses puts
them at the “sharp end” of healthcare in direct contact with patients. The chapter con-
cludes with an overview of efforts to increase healthcare transparency, improve public
reporting of healthcare, and reduce unwarranted variation in healthcare safety and
quality.

QUALITY OF CARE AND PATIENT SAFETY

The IOM considers patient safety both “indistinguishable from the delivery of
quality health care” (Aspden, Corrigan, Wolcott, & Erickson, 2004), and the foun-
dation of healthcare quality (Committee on the Quality of Health Care in America,
2001). Leaders in the United States have emphasized the need to redesign systems
of care to better serve patients in the complex environment of our healthcare sys-
tem. This has included efforts to inform policy through national policy reports,
such as the IOM Quality Chasm series of reports (IOM, 1999, 2001), healthcare
research and evaluation, and both federal and state policy changes to acceler-
ate safety and QIs. Federal and state regulatory agencies have implemented new
quality and safety requirements and financial penalties for poor quality care and
care that has harmed patients. There have also been several national initiatives to
improve quality and safety, such as the Institute for Healthcare Improvement’s
(IHI) Transforming Care at the Bedside (IHI, 2017a), 5 Million Lives Campaign (IHI,
2017b), and the Triple Aim (IHI, 2017c). The Centers for Medicare and Medicaid
Services (CMS) have also stopped reimbursement for extra healthcare costs associ-
ated with events that harm patients that are considered preventable. Yet, despite
these many efforts, both government agencies, such as the Agency for Healthcare
Research and Quality (AHRQ), and national healthcare quality organizations, such
as the Leapfrog Group, report that there have been some improvements in quality
and safety, but disparities and problems with quality and safety persist (AHRQ,
2011; The Leapfrog Group, 2017).

KEY TERMS USED WITH QUALITY AND SAFETY

Healthcare quality is defined as “the degree to which healthcare services for indi-
viduals and populations increase the likelihood of desired health outcomes and
are consistent with current professional knowledge” (IOM, 2001). High-quality
care is defined as care that is safe, timely, effective, efficient, equitable, and patient
centered (also referred to as STEEEP) with no disparities between racial or ethnic
groups (IOM, 2001). AHRQ expanded the definition of quality to include, “doing
the right thing, at the right time, in the right way, to achieve the best possible
results” (AHRQ, 2011). The IOM has recommended that quality can be improved
on four levels:

• The patient level
• The health-delivery “microsystems” level, such as a surgical team or acute-care

unit
• The organizational level, such as hospitals and healthcare systems
• The regulatory and financial environment level in which those organizations oper-

ate (IOM, 2001)

6 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

Errors are defined as “an act of commission (doing something wrong) or omission
(failing to do the right thing) leading to an undesirable outcome or significant poten-
tial for such an outcome” (Wilson, Harrison, Gibberd, & Hamilton, 1999). Unfortu-
nately, most errors in healthcare are viewed as a reflection of an individual’s lack of
knowledge or skill. Thus, when an error occurs, you will see efforts to blame or pun-
ish an individual. Yet, when considering the context in which healthcare errors occur,
errors are usually a reflection of human failings within poorly designed systems. From
this systems perspective, after an error occurs, we must try to identify factors that most
likely led to the error and find solutions and changes to current healthcare processes
so that we can reduce the possibility of a recurrence of the error or reduce the impact
of the error on patients.

An adverse event, which may be considered either preventable or not, is defined as
any undesirable experience in which harm resulted to a person receiving healthcare that
“requires additional monitoring, treatment, or hospitalization, or that results in death”
(IOM, 1999). Preventable adverse events are considered to reflect care that falls below
the standard of care. Serious preventable adverse events are generally defined as an
adverse event that is preventable and results in a patient death, loss of a body part, dis-
ability, or loss of bodily function lasting for more than 7 days or still present at the time
of discharge. The U.S. Food and Drug Administration (FDA), expands this definition to
focus on any undesirable experience associated with a medical product, such as a medi-
cation or medical device. In such instances, the undesirable experience is considered an
adverse event and should be reported to the FDA when, for example, the patient:

• Dies
• Experiences a life-threatening reaction
• Has an initial or prolonged hospitalization resulting from the adverse event
• Experiences “significant, persistent or permanent change, impairment, damage or

disruption” of normal function
• Needs a “medical or surgical intervention” because of an adverse event (FDA,

2016)

When there are problems or an adverse event occurs with any medication or medical
device, health professionals and consumers/patients can report the event online
via the FDA Adverse Event Reporting System (FAERS) (www.fda.gov/Drugs/
GuidanceComplianceRegulatoryInformation/Surveillance/AdverseDrugEffects/
default.htm) or MedWatch (www.fda.gov/Safety/MedWatch/default.htm). Adverse
events can also be reported to the organization where the event took place through
incident reporting systems, if appropriate, and/or to a state adverse event reporting
system or health department, depending on the state.

Sentinel events (sometimes referred to “never events” or “serious reportable
events”) are defined as any unanticipated event in a healthcare setting that reaches a
patient and results in any of the following:

• Death
• Permanent harm
• Severe temporary harm and intervention required to sustain life (The Joint

Commission [TJC], 2017a)

When a sentinel event occurs that results in death or serious physical or psychologi-
cal injury to a patient that is not related to the natural course of the patient’s illness,
it should be (but is not required to be) reported first within the organization accord-
ing to policy because these types of events, which are rare occurrences, should never

1 OVERVIEW OF PATIENT SAFETY AND QUALITY OF CARE • 7

happen. There are 29 types of sentinel events/serious reportable events (the full list
is available at http://www.qualityforum.org/Topics/SREs/List_of_SREs.aspx),
including:

• Surgery on the wrong patient, at the wrong site, or a wrong procedure surgery
• Suicide in a hospital or within 72 hours of discharge
• Falls
• Delay in treatment
• Medication errors
• Surgical instrument or object left in a patient after a surgery or other procedure

(National Quality Forum [NQF], 2017)

When a sentinel event occurs, the healthcare organization is “strongly encouraged,”
but not required, to report the sentinel event to The Joint Commission (TJC) and is
“expected to conduct thorough and credible comprehensive systematic analyses (e.g.,
root cause analyses), make improvements to reduce risk, and monitor the effectiveness
of those improvements” (TJC, 2017b). Patients, family members, staff, and the media
can also report patient safety events to TJC. Note that the reporting of most sentinel
events to TJC is voluntary and represents only a small proportion of actual events
(Table 1.1).

CAUSES OF ERRORS

Everyone can make mistakes. Errors in providing healthcare to patients and their families
are caused by a variety of factors, such as incompetency, lack of education or experience,
inaccurate documentation, language barriers, fatigue, and inadequate communication
among clinicians (Weingart, Wilson, Gibberd, & Harrison, 2000). Errors are also associ-
ated with extremes of age, new procedures, urgent conditions, and the severity of the
medical condition being treated (Palmieri, DeLucia, Ott, Peterson, & Green, 2008).

NATIONAL HEALTHCARE ORGANIZATIONS INFLUENCING
QUALITY AND SAFETY

While the initial estimates in the IOM’s To Err Is Human report proclaimed that each
year there were about 98,000 preventable deaths, recent research by Makary and
Daniel (2016) has found that more than 250,000 deaths each year are the result of

TABLE 1.1 SENTINEL EVENT DATA, 2014 TO SECOND QUARTER, 2017

Retention of foreign body 400 sentinel events
Wrong-site surgery 325 sentinel events
Fall 300 sentinel events
Suicide 300 sentinel events
Delay in treatment 250 sentinel events
Operative/postoperative complication 150 sentinel events
Criminal event 100 sentinel events
Medication error 100 sentinel events
Perinatal death/injury 100 sentinel events

Numbers are approximate. The reporting of most sentinel events to TJC is voluntary.
Source: The Joint Commission. (2017). Sentinel event data general information 2Q 2017 Update. Retrieved from
www.jointcommission.org/assets/1/18/General_Information_2Q_2017.pdf

8 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

errors within healthcare. That means that after heart disease and cancer, patient
safety errors are the third leading cause of death in the United States (Makary &
Daniel, 2016). Recognizing these and other challenges within healthcare, national
healthcare organizations provide resources and incentives to improve quality of care
and patient safety.

There are three key agencies within the U.S. Department of Health and Human
Services that are influential in encouraging improvements in healthcare quality and
patient safety. These agencies include AHRQ, CMS, and FDA. The AHRQ (www.
ahrq.gov) is focused on producing evidence to make healthcare safer, higher quality,
more accessible, and equitable, and working to make sure that evidence is under-
stood and used. The CMS (www.cms.gov) has multiple roles in influencing the
quality of care and patient safety. The CMS works with both public and private
organizations to ensure quality care, promote efficient health outcomes, and make
sure that CMS policies are used by healthcare organizations and clinicians to receive
reimbursement payments for their services to improve patient outcomes. The FDA
(www.fda.gov) is responsible for protecting the public health by ensuring the safety,
efficacy, and security of human and veterinary drugs, biological products, and medi-
cal devices; and by ensuring the safety of our nation’s food supply, cosmetics, and
products that emit radiation (FDA, 2017).

Several organizations, particularly the organizations listed in the following sec-
tion, have significant roles in influencing the quality of care and patient safety. These
organizations influence healthcare safety and quality by working with government
organizations, healthcare organizations, and healthcare clinicians, as well as accredita-
tion organizations:

• The Institute for Safe Medication Practices (ISMP) is a private nonprofit
organization that leads efforts to improve how medications are used by pre-
venting medication errors and promoting safe medication use, through its
national Medication Errors Reporting Program, which collects medication error
reports from healthcare professionals, and the Medical Error Recognition and
Revision Strategies program, where ISMP works directly and confidentially
with pharmaceutical companies to prevent errors associated with confusing
or misleading medication naming, labeling, packaging, and device design
(www.ISMP.org).

• The National Academy of Medicine (NAM), formerly the IOM, provides peer-
reviewed evidence-based information and advice concerning health and health
policy issues. The NAM released a series of 11 reports on quality and patient
safety, starting with its seminal report, To Err is Human: Building a Safer Health
System (IOM, 1999), followed by Crossing the Quality Chasm (IOM, 2001). The IOM
also released the report, The Future of Nursing: Leading Change, Advancing Health,
which sets forth a series of recommendations for nursing to have a greater role in
the complex U.S. healthcare system (IOM, 2013).

• The National Quality Forum (NQF) is a private nonprofit organization that con-
ducts review processes and works with stakeholders to standardize healthcare
performance measures. NQF has certified 34 separate healthcare practices and
procedures to be effective in reducing the occurrence of adverse events. A National
Priorities Partnership, convened by the NQF, has issued sets of specific actions to
reduce healthcare costs in three important areas, i.e., avoiding hospital readmis-
sions, reducing emergency department overuse, and preventing medication errors
(www.qualityforum.org).

1 OVERVIEW OF PATIENT SAFETY AND QUALITY OF CARE • 9

• IHI is a private nonprofit organization that motivates and builds the will for
change, partnering with patients and healthcare professionals to test new models
of care and ensuring the broadest adoption of best practices and effective innova-
tions (www.ihi.org).

• TJC, formerly named the Joint Commission on Accreditation of Healthcare
Organizations, is a private nonprofit organization that operates accreditation
programs for a fee to subscriber hospitals and other healthcare organizations.
Generally, TJC ensures that quality compliance requirements are met, includ-
ing core measures, safe practice measures, and process improvement efforts to
accredit a hospital. It is also known for its standards and tools aimed at ensuring
quality of care and patient safety, such as the Sentinel Event Policy, Improving the
Root Cause Analyses and Actions (RCA2) methodologies and techniques, and the
National Patient Safety Goals (www.JointCommission.org).

• The Leapfrog Group is a private nonprofit organization that collects and reports
its Leapfrog Hospital Survey on hospital performance to improve the value
of care and, through its Leapfrog Hospital Safety Grade, assigns letter grades
to hospitals based on how they perform on patient safety measures (www.
leapfroggroup.org).

• Healthcare Financial Management Association (HFMA) represents leaders in
healthcare finance with broad-based stakeholders in healthcare to provide edu-
cation and coalition building to improve healthcare through best practices and
standards. Through its Value Project, HFMA identified patient quality concerns
including “access, make my care available and affordable; safety, don’t hurt me;
outcomes, make me better; and respect, respect me as person, not a case” (HFMA,
2015; Table 1.2)

There are also some efforts to collect and provide information on performance
measurement data to consumers, physicians, and others. Data from CMS Hospital
Compare provides information on the quality of care provided to patients at hos-
pitals. The information that enables consumers to compare hospitals, which can be
accessed at, www.medicare.gov/hospitalcompare, is organized into several catego-
ries, including

• Survey of patients’ experiences (Hospital Consumer Assessment of Healthcare
Providers and Systems [HCAHPS])

• Timely and effective care
• Complications
• Readmissions and deaths
• Use of medical imaging
• Payment and value of care (CMS, 2017a)

TABLE 1.2 PATIENT QUALITY CONCERNS

ACCESS MAKE MY CARE AVAILABLE AND AFFORDABLE

Safety Do not hurt me
Outcomes Make me better
Respect Respect me as person, not a case

Source: Healthcare Financial Management Association (HFMA). (2015). Value in health care:
Current state and future directions. Westchester, IL: Healthcare Financial Management
Association. Retrieved from http://www.hfma.org/valueproject/valuesourcebook/

10 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

MEASURING QUALITY AND SAFETY

Work by the AHRQ, CMS, and NQF has led the development of measures for improv-
ing the quality of care and patient safety. Many of these measures depend on the occur-
rence of adverse patient outcomes or injury (measures of patient safety) while others
raise the standard of care by ensuring that recommended care is available and used by
all patients at the right time (measures of quality of care). When considered together,
these measures can help healthcare organizations improve the value of care they pro-
vide to all patients.

There are several examples of quality care and patient safety measures that
are used primarily in healthcare organizations, such as hospitals, nursing homes,
and outpatient clinics. The major sets of measures include the CMS Core Measures,
AHRQ Quality Indicators, AHRQ Patient Safety Indicators, NQF and American
Nurses Association (ANA) Nurse Sensitive Indicators, and the National Committee
for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set
(HEDIS) Measures (Table 1.3). Many professional organizations and other health-
care organizations also have quality of care and patient safety measures that can be
found through websites of professional organizations and in peer-reviewed journal
publications.

The case manager at a community hospital was reviewing occurrence report
data trends over the last quarter. There appeared to be an increasing trend of
patients who are not appropriate candidates for an MRI due to the patients
having implanted metal devices. The lead MRI technologist is very con-
cerned that these patients are not being correctly screened by the nurses on
the unit.
The risk manager put together an interprofessional team from the nursing, medi-
cal, and MRI departments. After reviewing the MRI screening process, it was
discovered that a new scheduling system that had been put in place in the radiol-
ogy department was so efficient at getting patients an MRI appointment, the unit
nurses did not have time to complete an MRI patient screening after the doctor
had ordered it. A new MRI screening process was immediately implemented.
The MRI order would now not be placed by the unit secretary until the RN com-
municated that the MRI patient screening was completed. Note that the problem
reported by MRI staff led to the work process change. This protected patients
from a potential injury.

1. Why is it important that patients with implants be identified on the unit by the nurse
rather than later by the MRI technologist?

2. How did the Risk Management process of reviewing the MRI screening process help
with this patient safety issue?

CASE STUDY 1.1

1 OVERVIEW OF PATIENT SAFETY AND QUALITY OF CARE • 11

TABLE 1.3 EXAMPLES OF MEASURES OF PATIENT SAFETY AND MEASURES OF QUALITY
OF CARE

MEASURE SET A FEW EXAMPLES OF THE MEASURES WHERE USED

Core Measures (CMS,
2017b)

• Used to improve
quality of care for
common conditions

• www.cms.gov/
Medicare/Quality-
Initiatives-Patient-
Assessment-
Instruments/
QualityMeasures/Core-
Measures.html

• www.cms.gov/
Medicare/Quality-
Initiatives-Patient-
Assessment-
Instruments/
QualityMeasures/Core-
Measures.html

• Stroke: Received medication to
prevent blood clots

• Immunization: Assessed for flu
vaccine

• Heart failure: Received beta
blocker therapy for left ventricular
systolic dysfunction

• Age appropriate screening
colonoscopy

• Readmission: All-cause readmission
rate following elective total hip or
total knee replacement

• Hospitals
• Health plan/

integrated
delivery
systems

• Individual
clinician level

Patient Safety
Indicators (AHRQ,
2017a)

• Used to improve the
safety of inpatient care

• www.qualityindicators.
ahrq.gov/modules/
psi_overview.aspx

• Rate of pressure ulcers
• Retained surgical item or

unretrieved device fragment count
• Rate of central venous catheter-

related blood stream infections
• Rate of postoperative sepsis
• Transfusion reaction count
• Rate of accidental punctures or

lacerations
• Rate of birth trauma—injury to

neonate

Hospitals

Quality Indicators
(AHRQ, 2017b)

• Used to improve
quality of care

• qualityindicators.ahrq.
gov

Prevention Quality Indicators
• Perforated appendix admission rate
• Hypertension admission rate
• Urinary tract infection admission rate
• Uncontrolled diabetes admission rate
• Bacterial pneumonia admission rate

Hospitals

Inpatient Quality Indicators
• Hip replacement mortality rate
• Heart failure mortality rate
• Acute stroke mortality rate
• Laparoscopic cholecystectomy rate
• Hysterectomy rate

Hospitals

(continued)

12 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

CRITICAL THINKING 1.1

Each year, hospitals, healthcare systems, and healthcare providers report quality
measures to national organizations. They also use these measures to assess their overall
performance and they generally group these quality measures into several key strategic
areas:
• Quality and safety of care
• Patient satisfaction/experience
• Workforce issues

(continued)

MEASURE SET A FEW EXAMPLES OF THE MEASURES WHERE USED

Pediatric Quality Indicators
• Neonatal mortality
• Pressure ulcers
• Transfusion reactions
• Postoperative hemorrhage or

hematoma
• Postoperative respiratory failure

Hospitals

Nurse Sensitive
Indicators (ANA, 2010;
NQF, 2004)

• Used to improve the
quality of nursing care

• www.qualityforum.
org/improving_care_
through_nursing.aspx

• Falls with injury
• Nursing care hours per patient day
• Pressure ulcers
• Rate of nosocomial infections
• Staffing mix (ratios of RNs, LPNs,

and unlicensed staff)

Hospitals

HEDIS (NCQA, 2017)
• Used to measure

performance in care
and services

• www.ncqa.org/hedis-
quality-measurement/
hedis-measures

• Childhood immunizations status
• Colorectal cancer screening
• Medication management for people

with asthma
• Controlling high blood pressure
• Annual dental visit

• Outpatient
clinics and
offices

• Other
organizations
(e.g., health
insurance
company)

URAC
• Used to assess QI with

organizations
• www.urac.org/

standards-and-
measures-glance

• Patient and family member
engagement

• Effectiveness of communications
and service coordination between
providers and across providers and
their patients

• Errors and infections associated with
harm and death

• Variety of
healthcare
programs (e.g.,
healthcare
management
programs,
provider
integration and
coordination
programs)

HEDIS, Healthcare Effectiveness Data and Information Set; LPN, licensed practical nurse; URAC, Utilization Review
Accreditation Commission.

TABLE 1.3 EXAMPLES OF MEASURES OF PATIENT SAFETY AND MEASURES OF QUALITY
OF CARE (continued )

1 OVERVIEW OF PATIENT SAFETY AND QUALITY OF CARE • 13

UNWANTED VARIATION IN HEALTHCARE QUALITY AND
SAFETY

Unwanted variation is variation in the use of medical care that cannot be explained on
the basis of illness, medical evidence, or patient preferences, Wennberg, as reported by
McCue (2003) has categorized four types of variation:

• Variations from the underuse of effective treatments or intervention that has been
shown in clinical studies to improve health status or quality of life, for example,
the use of beta blockers postmyocardial infarction

• Variations in outcomes attributable to the quality of care, for example, increased
mortality following surgery

• Variations from the misuse of preference-sensitive services, for example, hysterec-
tomy versus hormone treatment

• Variations from the overuse of supply-sensitive services, for example supplies that
are overused because they are easily available to patients and healthcare practition-
ers, for example, medications and various technologies

There is variation in healthcare in various areas of the United States, variation pro-
vided by different healthcare providers and agencies, and variation in services
available to different socioeconomic groups. There is also significant variation in what
healthcare providers charge for different services. Nurses and the interprofessional team
must work to reduce variation and improve healthcare service delivery to all patients.

TRANSPARENCY AND REPORTING PERFORMANCE

Healthcare clinicians, insurance companies, state and federal governments, patients and
their families, and many others have the opportunity to improve patient safety and the
quality of healthcare. National and state efforts to motivate improvements in healthcare
have included financial incentives, regulation, accreditation, and public reporting. Of
these, public reporting of performance is thought to be the best motivator for improv-
ing patient safety and quality of care. When organizations and clinicians are transpar-
ent in reporting their performance against quality measures, it is believed that they are
being accountable, that they ethically respond to failures (Leape, 2010), and that they are

CRITICAL THINKING 1.1 (continued)

• Financial performance
• Strategic sustainability and growth)

Explore one of the websites in Table 1.3 for one of the measures described there. Think
about how nurses can use these measures to improve nursing care and patient outcomes
in these five key strategic areas.

1. How can nursing care and patient outcomes be improved by reviewing
patient satisfaction measures?

2. How can nursing care and patient outcomes be improved by reviewing
quality and safety of care?

14 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

informing consumer choice (Berwick, James, & Coye, 2003). In most instances,
transparency is considered to include reporting not only the real cost of care, but
also clearly reporting information about performance failures as well as successes
(Pronovost et al., 2016). Major domains of healthcare transparency include the following:

• Clinical quality
• Resource use
• Efficiency
• Patient experience of care
• Professionalism
• Healthcare system/facility recognition and accreditations for meeting national

standards
• Financial relationship of physicians and other healthcare professionals
• Financial relationship between physicians and other healthcare professionals, and

industry
• Health insurance company processes (American College of Physicians [ACP], 2010)

Improvement of how care is delivered and improvement in patient outcomes from
care received is a labor-intensive process that uses many staff and financial resources.
Improvement processes include accurately looking at errors that occur from provid-
ing care; looking at areas where the quality of care can be improved through the early
detection, prevention, and reporting of errors; and looking at improving performance on
measures of quality care. Yet reporting errors or problems in quality of care is not straight-
forward. Federal and state governments, as well as private organizations have used man-
datory reporting systems for errors and instances of poor quality of care, yet they are
often not effective because of the fear that clinicians have of being punished, for example,
with financial fines or punitive actions. As a result, errors continue to be underreported.

In many states, when a serious preventable adverse event occurs in a healthcare
facility, for example, a hospital, nursing home, and so on, that is licensed by a state
government, the facility is required by state law to report the event to their state gov-
ernment. However, it is important to note that while the majority of states have this
requirement, not all states require this. TJC also has a voluntary reporting system.

Relatedly, it is also important to report successes and achievements in patient safety
and quality of care within an organization. For example, reports of positive nursing
sensitive indicators of high-quality care include achievement of appropriate self-care,
demonstration of health-promoting behaviors, achievement of positive health-related
quality of life, perception of being well cared for, and good symptom management.
Mortality (i.e., death), morbidity (i.e., disease), and adverse events are considered
negative outcomes by both clinicians and external organizations. Reporting successes
can be helpful in understanding if an organization or clinicians are able to sustain and
attain goals in safety and quality.

Patient safety and quality of care can improve in organizations committed to
safety and quality throughout the organization. Unfortunately, not all organizations
are committed to improving patient safety and quality. Nurses report that there is a
lack of a blame-free environment and problems with leadership support to establish
and maintaining a culture of safety (Wolf & Hughes, 2008). The barriers for attaining a
culture of safety include lack of leadership, a culture where low expectations prevail,
poor teamwork, and poor communication. Optimally, everyone, at all levels within an
organization, would work in a culture of safety where there is

• Acknowledgment of the high-risk nature of an organization’s activities and the
determination to achieve consistently safe operations

1 OVERVIEW OF PATIENT SAFETY AND QUALITY OF CARE • 15

• A preoccupation with safety
• An emphasis on systems improvement to support performance
• Organizational commitment of resources and encouragement of collaboration

across ranks and disciplines to seek solutions to patient safety concerns
• Encouragement of collaboration to find solutions for patient safety problems
• Proactive reporting of unsafe conditions
• A just culture (or culture of justice) response to error, which includes frequent

debriefing and sharing of “lessons learned,” and which has an atmosphere of
teamwork within a blame-free environment with mutual respect, which enables
candid discussion among employees, where patient safety concerns are dealt with
quickly (AHRQ, 2017c)

Safety culture is generally measured by surveys of providers at all levels. Available
validated surveys include AHRQ’s Patient Safety Culture Surveys (available at psnet.
ahrq.gov/resources/resource/5333) and the Safety Attitudes Questionnaire (available
at psnet.ahrq.gov/resources/resource/3601).

THE CONSEQUENCES OF WHEN THINGS GO WRONG

Errors in healthcare that harm patients cost approximately $17.1 billion each year (Van
Den Bos et al., 2011). It has been estimated that, while hospitalized, about one in four
patients experience one or more adverse events that result in a longer hospital stay,
permanent harm, the need for a life-sustaining intervention, or death. Of these adverse
events that resulted in injury, almost half were preventable (Office of the Inspector
General [OIG], 2010).

Errors happen because of a multitude of factors, such as lack of education or expe-
rience, misdiagnosis, under-and over-treatment, urgency, and fatigue (IOM, 1999).
Patient harm during a hospitalization is also impacted by nurses. The more times a
hospitalized patient is exposed to below targeted nurse staffing levels, the greater the
risk for patient mortality (Needleman et al., 2011). While nurses are capable of prevent-
ing the majority of errors from harming a patient, all errors need to be reported (Wolf
& Hughes, 2008) by the members of the healthcare team, not just nurses. The team
needs to work together to mitigate (or minimize the amount of) the effects of an error
for the patient.

As part of national efforts to reform Medicare, and in an effort to encourage hos-
pitals to improve the quality and safety of care, CMS and many private insurance
companies require hospitals to report the occurrence of sentinel events and will apply
a financial penalty to the hospital if and when sentinel events do occur. Sentinel events
(e.g., mortality, readmissions within 30-days of discharge, and wrong-site surgery) are
considered to be preventable and should not happen. When they do happen, the hos-
pital will not be reimbursed for the cost of care associated with the cost of care for the
aftermath of the sentinel event (e.g., longer hospital stays, a corrective surgical proce-
dure) from CMS. CMS (and now many private insurance companies) will also not pay
for conditions related to Never Events, including:

• Certain serious pressure ulcers
• Acquired urinary tract infections from catheter use
• Acquired blood stream infections from catheters
• Air embolism
• Giving the wrong blood type
• Foreign objects left in surgical patients (CMS, 2008)

16 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

In some instances, errors that cause patient harm result in a medical malpractice law-
suit. Approximately $55.6 billion in 2008 or 2.4% of total U.S. healthcare spending
is estimated to be spent on medical liability. Medical liability includes items such as
malpractice payments to patients, attorneys’ fees and other legal expenses for both
sides, and defensive medicine costs, which are the costs of medical services ordered
primarily for the purpose of minimizing the physician’s liability risk (Mello, Chandra,
Gawande, & Studdert, 2010).

PROFESSIONAL RESPONSIBILITIES FOR NURSES

Nurses are key to ensuring and improving quality of care and patient safety for
patients and families, as well as for the organizations in which they work. Quality
and Safety Competencies, developed as part of the Quality and Safety Education for
Nurses (QSEN) initiative, that identify knowledge, skills, and attitudes that nursing
students should achieve as part of their prelicensure programs and be able to exem-
plify in practice. They include the following:

• Patient-centered care
• Teamwork and collaboration
• Evidence-based practice (EBP)
• QI
• Safety
• Informatics (QSEN, 2014)

It is important to understand that the best way to exemplify these six competencies in
practice is to apply each competency within the wider context of complex healthcare
systems, which has not been the traditional approach for healthcare clinicians that
have been educated to focus at the individual point of care (Dolansky & Moore, 2013).
In other words, clinicians tend to focus on the individual patient and their family, not
necessarily how that patient and their family affect and are affected by the larger popu-
lation and system of care. As such, to effectively apply each of the six competencies
within the wider context of complex healthcare systems, nurses need to think about
how performance can be measured, how the strengths of each team member can be
maximized to improve care delivery to patients and improve their outcomes, and what
can be done in the healthcare system to assure quality and safety and prevent harm
from unintended consequences from errors. To take this one step further, in some cir-
cumstances, it is important to think about how nurses can accomplish QI and patient
safety within organizations that may not truly have a culture of safety. It can be very
difficult to improve quality and patient safety within an organization that does not
have a culture of safety.

CRITICAL THINKING 1.2

In thinking about what you are learning in nursing school about patient safety and
quality of care, go to http://qsen.org/competencies/pre-licensure-ksas/ and explore the
specifics of each of the six QSEN competencies.

(continued)

1 OVERVIEW OF PATIENT SAFETY AND QUALITY OF CARE • 17

PREVENTING AND RESPONDING EFFECTIVELY TO
ADVERSE EVENTS

Strategies to reduce unwarranted variation and ensure predictable and favorable
patient-care outcomes have proven successful in improving healthcare quality and
patient safety. These strategies include developing checklists and other standard-
ized tools, using best practices, and working in an organization with a culture of
safety and communication when an error does occur. Checklists have been proven
successful particularly in operating rooms and other areas where multiple tasks
need to be accomplished consistently to ensure quality and safety. Checklists have
demonstrated that they protect against failure, they establish a higher standard of
baseline performance, and they are only an aid if they are done right to begin with
(Gawande, 2011).

Standardized communication tools such as the SBAR (Situation, Background,
Assessment, Recommendation) technique (www.ihi.org/resources/Pages/Tools/
SBARTechniqueforCommunicationASituationalBriefingModel.aspx), and using stan-
dardized order sets, protocols, and other best practices can be used by nurses and other
members of the healthcare team to prevent errors, ensure quality care, and reduce vari-
ability in patient care and the potential for error.

It is important for nurses to work in organizations dedicated to a culture of
safety and communication when an error does occur. Organizations that have a
culture of safety are nonjudgmental, acknowledge the risk and error-prone nature
associated with healthcare, and focus on improving healthcare systems and pro-
cesses. In that quality and patient safety errors are often systems related and are
not always attributable to individual negligence or misconduct, organizations that
foster a culture of safety continuously strive to intercept errors before they happen,
measure the quality of care processes and outcomes, and mitigate (or take action
to minimize) harm involving patients. Organizations with a true culture of safety
maintain an environment where nurses are not afraid to speak up and report errors
or potential errors.

When something goes wrong and patients are harmed, it is difficult for clinicians,
leadership, and patients. The first thing to remember is that when an adverse event
occurs, it is important to respond in a timely manner, and as the Leapfrog Group rec-
ommends, do the following:

1. “Apologize to the patient and family
2. Waive all costs related to the event and follow-up care
3. Report the event to an external agency
4. Conduct a root-cause analysis of how and why the event occurred
5. Interview patients and families, who are willing and able, to gather evidence for

the root cause analysis

CRITICAL THINKING 1.2 (continued)

1. What specific ways do you see the QSEN competencies being used in your
nursing courses?

2. What specific ways do you see quality and safety being practiced in your
clinical experiences?

18 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

6. Inform the patient and family of the action(s) that the hospital will take to pre-
vent future recurrences of similar events based on the findings from the root cause
analysis

7. Have a protocol in place to provide support for caregivers involved in Never
Events, and make that protocol known to all caregivers and affiliated clinicians

8. Perform an annual review to ensure compliance with each element of Leapfrog’s
Never Events Policy for each never event that occurred

9. Make a copy of this policy available to patients upon request” (Leapfrog Group,
2017)

One tool that health care organizations and providers can consider using to learn
more about being successful after an adverse event occurs is the Communication and
Optimal Resolution (CANDOR) kit. CANDOR is a communication and resolution pro-
cess designed to open lines of communication between clinicians, patients, and their
families after patient harm occurs. The free program (available at www.ahrq.gov/
professionals/quality-patient-safety/patient-safety-resources/resources/candor/
introduction.html), includes eight training modules and also encourages clinicians to
report near misses and errors to better inform patients (AHRQ, 2016).

WHY IS IT WRONG TO BLAME AND POINT FINGERS?

When errors occur, we seem to traditionally blame the nurse as causing the error since
many of the roles of nurses in patient care often put the nurse in direct contact with
patients. In the past, we have even gone so far as to blame nursing leadership for
“allowing” nurses to cause errors. By being in direct contact with patients, nurses are
in a unique position to most likely be the only person in the room with the patient or
the last person able to stop a chain of events that may result in an error. If a nurse is
unable to stop an error from happening, the nurse is seen as literally at the sharp end
of the arrow of blame. The term “sharp end” has been used to identify the important
and significant direct contact role that nurses at the bedside, closest to clinical activi-
ties, play in recognizing the need for and potential impact of practice changes. Nurses
may see the sharp end effects on patients and others first when the right care is not
provided. Front line clinical nurses (as well as nurses in formal leadership positions)
often assume leadership at the “sharp end” of care in direct contact with patients to
assure safety and quality.

Nurses are qualified to offer invaluable insights and perspectives about what is
preventing effective and efficient care as well as how the quality and safety of care can
be improved based on their skills and experience. Other contributing factors, whether
individual or health system related (e.g., such as the physician who may have ordered

CRITICAL THINKING 1.3

During your shift, you discover that the wrong medication was given to the wrong
patient. Hospitals have policies and procedures that should be followed when a patient
is given the wrong medication.

1. What are the policies and procedures at your clinical agency?
2. What do those policies state?

1 OVERVIEW OF PATIENT SAFETY AND QUALITY OF CARE • 19

the wrong medication, or the design flaw in the infusion pump that malfunctioned),
while maybe not in direct contact with the patient when the error occurred, also con-
tribute to errors.

CAN HEALTHCARE BE PERFECT?

The quality and safety of care does not just spontaneously improve, and in many
respects, it may not be possible to have error-free care that is of the highest quality
at all times and in all places. Generally speaking, something needs to be done or
someone needs to take action to either make improvements or ensure that a quality
standard is maintained. A key goal of healthcare is to reduce unwarranted variation
in healthcare safety and quality to ensure optimal patient outcomes. Yet even with
the understanding that the quality of healthcare in the United States and throughout
the world needs to improve, there is no consensus on how to best achieve consistent,
high-quality care.

One of the challenges we have in improving healthcare is that nurses tend to be
resilient—meaning that if something does not work well while they are providing care
to a patient, they work around the “normal” way of doing things. These workarounds
increase the opportunities for inconsistent care and inconsistent outcomes. Related to
this, patients can also at times be resilient. For example, some patients can take the
wrong medication at the wrong time and have no effects. Unfortunately, the resiliency
of nurses coupled with the resiliency of patients does not guarantee the best possible
outcomes nor does it ensure safe quality care.

Over the years, healthcare has become very complex. It involves multiple health-
care professionals and information from many sources. This complexity is closed
linked with increased opportunities or increased risk for something going wrong and
patients being harmed or the quality of care being compromised. Patients in hospitals
and those that receive care from multiple healthcare providers at multiple sites of care
are particularly vulnerable to safety and quality errors.

In an effort to ensure that safety is fundamental for every healthcare system, the
IOM asserted that “Patients should not be harmed by the care that is intended to help
them, nor should harm come to those who work in health care” (IOM, 1999).

IOM stated in its Crossing the Quality Chasm: A New Health System for the 21st Century
(IOM, 2001) report that the healthcare system should focus on six aims (Table 1.4).

TABLE 1.4 SIX “STEEEP” AIMS OF THE HEALTHCARE SYSTEM

Safe No one should ever be harmed by or as a consequence of receiving
healthcare services.

Timely Care should be obtained when needed with minimal delays.
Effective The best available evidence should guide how healthcare is delivered

to achieve the best possible outcomes.
Efficient The quality of care should be maximized at the lowest, possible cost.
Equitable Everyone should have equal quality of care even if patients may differ

in personal characteristics other than their clinical condition or
preferences for care.

Patient
centered

A patient’s culture, social context, and specific needs deserve
respect, and each patient should have an active role in making
decisions about their own care.

Source: Institute of Medicine (IOM). (2001). Crossing the Quality Chasm: A New Health System for the 21st Century.
Retrieved from https://www.nap.edu/catalog/10027/crossing-the-quality-chasm-a-new-health-system-for-the

20 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

I live in the state of Georgia and up to this year, I have purchased individual
coverage through Blue Cross and Blue Shield (BCBS) of Georgia. The cost has
increased substantially in the last few years, but at least I was able to sign up
for a preferred provider organization (PPO) plan. BCBS has notified me that
they pulled out of the individual market for 2018. Thus, today I spent sev-
eral hours looking for health insurance. None of the large companies (BCBS,
United Healthcare, AETNA, Humana, etc.) offer individual health insurance
coverage in Georgia. It looks like the best I can do is to sign up for a Health
Maintenance Organization (HMO) with Kaiser Permanente HMO, which
costs just under $900 per month. They do not offer PPOs for individuals in
Georgia and only their Signature HMOs are available to me at all three HMO
levels (bronze, silver, and gold). This offers a very limited number of doc-
tors and hospitals near me. It is crazy, but it is the best I can do. The Kaiser
Signature HMOs require me to find a general practitioner within their net-
work of doctors that accept my plan. If I need a specialist, they will refer me
to one in their network. However, for each HMO level, there are only a few
doctors within 10 miles of my home and only one major hospital that accepts
my HMO. This will be the first time in my life that I have an HMO. It is also
the most I have ever paid for health insurance. The plan I am signing up for
now will only cover 70% of expenses. I will have to pay 30% of expenses out
of pocket. Going to an HMO means that I will not be able to go outside a pre-
scribed network of HMO doctors in Georgia.

At present, the healthcare situation in the United States for middle class
individuals like me that have to pay for our own health insurance is sub-
optimal. I have lived in several countries in Europe and Latin America and
never found myself in this predicament. Usually, the healthcare is covered
by some sort of national insurance. If you are middle class, you can afford to
either purchase a private health insurance plan or simply pay out of pocket,
since the cost of medical procedures and prescriptions is a lot more reason-
able. In the United States, the costs of medical treatment and prescriptions
are prohibitive without medical insurance. For example, if I were to get seri-
ously sick and need treatment in a place like Spain or Panama, I could make
an appointment with any specialist in a private clinic or hospital and pay out
of pocket a lesser amount than the cost of my 30% insurance charges in the
United States For instance, a doctor’s visit in Spain or Panama costs less than
$100. A specialist costs slightly more. You can get a full checkup including full
blood and urine tests, Pap test, mammogram, and dermatologist check up
from $500 to $700. Most common surgeries cost a few thousand dollars, not
tens of thousands of dollars like in the United States. If you are a middle-class
person there, you may not even need to have insurance. Medical tourism to
other countries is growing fast in the United States, as you can obtain treat-
ment in a foreign country, pay out of pocket, and it will cost you less than the
out of pocket healthcare expenses in the United States, even with the travel
expenses involved.

O. H.
Atlanta, GA

REAL-WORLD INTERVIEW

1 OVERVIEW OF PATIENT SAFETY AND QUALITY OF CARE • 21

The 2001 IOM report further noted that by focusing on these six aims, a transfor-
mation will begin to occur in the healthcare system. In another report, the IOM stated
that healthcare systems needed to be redesigned to improve quality of care and patient
safety, but to do so, organizations needed to meet these six challenges:

1. Redesign care processes
2. Make effective use of information technologies
3. Manage clinical knowledge and skills
4. Develop effective teams
5. Coordinate care across patient conditions, services, and settings over time
6. Incorporate performance and outcome measurements for improvement and

accountability (IOM, 2001)

INTERNATIONAL ADVANCES IN QUALITY AND SAFETY

Researchers and healthcare providers throughout the world have been actively
involved in improving patient safety and quality of care. Significant research and
practice innovations have been developed primarily in the United Kingdom, Canada,
Australia, and the United States. Research across the world on strategies to under-
stand and improve healthcare quality and patient safety can be found throughout
peer-reviewed healthcare journals.

Even though some may consider the United States as the leader in healthcare
or in efforts to improve healthcare quality and patient safety, comparative stud-
ies by the Organization for Economic Cooperation and Development (OECD), the
United Kingdom, and The Commonwealth Fund, among others, have consistently
found that the United States does not have better healthcare outcomes than other
industrialized nations, including countries in Europe, Australia, Canada, and New
Zealand (The Commonwealth Fund, 2014; The Commonwealth Fund, 2015; The
Health Foundation, 2015; OECD, 2017). Poor U.S. healthcare outcomes do not make
sense when you consider the fact that year after year, the United States continues to
spend more on healthcare (per capita), than any other country in the world (OECD,
2017). Higher spending appears to be largely driven by greater use and cost of
medical technology (Table 1.5) and higher drug and healthcare prices, rather than
by more frequent doctor visits or hospital admissions (Table 1.6). Despite spending
more on healthcare, Americans have poor health outcomes, including shorter life
expectancy, greater prevalence of chronic conditions, and higher infant mortality
rates (The Commonwealth Fund, 2017; Table 1.7).

TABLE 1.5 SELECTED COSTS OF MEDICAL TECHNOLOGY

MRI machine $1,541,788
OR table $65,263
Electric bed $15,981
Stretchers $7,618
Implantable pacemaker $3,820
Knee implant—femoral $1,970
Drug-eluting stent $1,189
Hip implant—acetabular shell $1,073

Source: Modern Healthcare. Technology price index. Retrieved from
http://www.modernhealthcare.com/section/technology-price-index

22 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

While organizations focused on improving the quality and safety of care have
been previously mentioned in this chapter, there are similar organization outside
the United States and even organizations within the United States that are focusing
on either country-specific goals or global initiatives. For example, the European
Medicines Agency and Health Canada have similar functions as the FDA in the
United States The U.S.-based Joint Commission, has an international component
that has established the International Patient Safety Goals that are used worldwide,
including:

1. “Identify patients correctly
2. Improve effective communication
3. Improve the safety of high-alert medications
4. Ensure safe surgery
5. Reduce the risk of healthcare-associated infections
6. Reduce the risk of patient harm resulting from falls” (Joint Commission International

[JCI], 2017)

Each of these international goals can be related to the U.S.-based Joint Commissions
patient safety goals. The World Health Organization (WHO) also continues to lead
worldwide efforts to improve patient safety (see www.who.int/patientsafety/en as an
example). And since 1998, the Australian Patient Safety Foundation has also led key
initiatives to improve patient safety (see apsf.net.au).

As these and other countries became involved in focusing on improving quality
and safety of healthcare, inconsistency continued in how patient safety terms were
used across nations, which hampered global advances to improve patient safety. The
World Alliance for Patient Safety, a part of the WHO, developed the International
Patient Safety Classification framework to facilitate a common understanding and use
of definitions and preferred terms for patient safety (WHO, 2009; see www.who.int/
patientsafety/taxonomy/icps_statement_of_purpose.pdf). Also, there has been incon-
sistency in how quality and safety of care is measured. The OECD developed a set of
indicators for comparing the quality of health across OECD member countries through
its Health Care Quality Indicator Project (see www.oecd.org/els/health-systems/
health-care-quality-indicators.htm).

TABLE 1.6 MEDICATION COSTS

UNITED STATES CANADA

100 mg of sitagliptin (Januvia) $382 $105.03
1 inhaler of Advair Diskus 250

mcg/50 mcg
$386.97 $131.87

dimethyl fumarate (Tecfidera) 60-capsule package of 120
mg costs $6,805.76 or
$113 per capsule

42 capsule supply
of 120 mg costs
$1,177.80, or
$28.04 per
capsule

Source: The Motley Fool. (2017). 5 drugs that are way cheaper in Canada. Retrieved from https://www.fool.com/
investing/2017/01/21/5-drugs-that-are-way-cheaper-in-canada.aspx

TABLE 1.7 U.S. HEALTHCARE FROM A GLOBAL PERSPECTIVE

Total
Healthcare
Spending
per Capitaa

Infant
Mortality
per 1000
Live Births,
2013

CT Scanners
per 1 Million
Population

Price Comparisons
for In-patient
Pharmaceuticals,
2010 United
States set to 100b

Life
Expectancy
at Birth

Percent of
Population
With Two
or More
Chronic
Diseases,
2014

United
Kingdom

$3,364 3.8 7.9 46 81.1 33

New Zealand $3,855 5.2c 16.6 81.4 37
Australia $4,115a 3.6 53.7 49 82.2c 54
France $4,361 3.6 14.5 61 82.3 43
Canada $4,569 4.8c 14.7 50 81.5c 56
Germany $4,920 3.3 – 95 80.9 49
Netherlands $5,131d 3.8 11.5 – 81.4 46
United States $9,086e 6.1c 43.5 100 78.8 68

a 2012.
b Price for basket of in-patient pharmaceuticals; lower number is lower price.
c Source, OECD Data, 2015.
d Current spending only; excludes spending on capital formation of healthcare providers.
e Adjusted for differences in cost of living.
Source: The Commonwealth Fund. (2017). U.S. health care from a global perspective. Retrieved from http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-
health-care-from-a-global-perspective

24 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

WHAT IS THE COST OF ACHIEVING QUALITY AND SAFETY

From a systems perspective, the cost of providing safety and quality care comes at a cost
(Table 1.8). Across types of healthcare organizations, there are many categories of costs,
primarily including the costs of healthcare salaries (Table 1.9), costs associated with the
technology used to provide healthcare services, and the cost of the physical space where
healthcare is delivered. Hospitals also have significant costs when it comes to ensuring
quality of care and patient safety. While some of these costs can be seen as high, the
cost of poor quality of care far exceeds these amounts. The majority of hospitals in the
United States (American Hospital Association [AHA], 2017) are required by the CMS
to meet TJC accreditation requirements to be reimbursed for care received by Medicare
and Medicaid beneficiaries, who represent the majority of hospitalized patients. There
are over 4,000 hospitals and approximately 77% of them are currently accredited by TJC
(2017). The accreditation process, which includes an expensive onsite survey, recurs every
3 years (JCI, 2017).

EVIDENCE FROM THE LITERATURE

Citation

Marsa, L. (2017, September). Take charge of your health care: Surgeries and side effects.
(p. 20).

Discussion

These are among the most common surgeries for Americans over 50 and the
most common complications. In 2% to 4% of all cases, complications happen, and
the patient needs to be readmitted to the hospital within 30 days.

SURGERY COMPLICATION OCCURRENCE

Cataract removal Posterior capsule opacity 20%
Pacemaker implant Hematoma 2.2% in patients over 70
Colectomy Infection 12.4%
Coronary artery bypass Atrial Fibrillation 24%
Hip replacement Dislocation 2%
Knee replacement Blood Clot 1%
Prostate removal Bleeding 5.3%
Inguinal Hernia Infection 0.3% Open surgery

0.2% Laparoscopic surgery
Cholecystectomy Infection 7.6% Open surgery

1% Laparoscopic surgery
Appendectomy Infection 4.3% Open surgery

1.9% Laparoscopic surgery

Implications for Nursing: Nurses must be aware of the higher incidence of
complications in patients over 50 and, when possible, implement nursing care
strategies to prevent complications.

1 OVERVIEW OF PATIENT SAFETY AND QUALITY OF CARE • 25

TABLE 1.8 SELECTED COSTS OF ACHIEVING QUALITY OF CARE AND PATIENT SAFETY

ORGANIZATION REQUIREMENT WHAT IS INVOLVED
AVERAGE ANNUAL
COST

Hospital Joint
Commission
Accreditation

• Meeting each of the
standards

• Planning for the survey
• Staff time in record

keeping and treatment
planning

• Conducting a mock
survey

• Actual survey

Approximately
0.03% to 1%
of a hospital’s
operating budget.
Annual fees are
based on type of
hospital, volume,
and types of
services provided
(TJC, 2017c)

Home care
agency

Joint
Commission
Accreditation

• Meeting each of the
standards

• Planning for the survey
• Staff time in record keeping

and treatment planning
• Conducting a mock survey
• Actual survey

Average of $1,500
for single-service
home care
providers, and
onsite survey fee
of $3,240 (TJC,
2015)

Healthcare
organization

Director of QI • Lead and direct process
improvement activities
to provide efficient and
effective care

Average salary =
$109,293 (range
$95,713-$127,272)
(Salary.com)

Healthcare
organization

Nursing
informatics
specialist

• Manage information and
communications (including
documentation) for nursing

Average salary =
over $100,000
(HIMSS, 2017)

Hospital Magnet®
Accreditation

• Performing a gap analysis
to identify problems

• Meeting each of the
Magnet® requirements

• Preparing and submitting
an application and required
documentation

• Actual site visit survey

Average annual
cost of $500,000
(total average
investment of
$2,125,000
over several
years) (Robert
Wood Johnson
Foundation
[RWJF], 2014)

Healthcare
organization

Baldrige
Award

• Meeting each of the
criteria

• Preparing and submitting
an application and
required documentation

Eligibility certification
= $400 (initial cost)
then the

application fee
= $10,560
to $19,800,
supplemental
section = $1,100
to $2,200, and site
visit = $33,000
to $66,000
(National Institute
of Standards and
Technology [NIST],
2016)

Source: Glassdoor. (2017). Salary.com Salaries. Retrieved from https://www.glassdoor.com/Salary/Salary-com-Salaries-
E35301.htm

26 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

There are also costs and savings for outpatient organizations when it comes to
improving quality of care. For example, improving a patient’s glucose management
would increase the average cost per individual with diabetes by $327 per year, but
would save between $555 to $1,021 annually (Nuckols et al., 2011).

Preventing hospital-acquired conditions (HACs), such as adverse drug events, falls,
pressure ulcers and healthcare associated infections, can avert death. For example, about
44% of HACs are considered preventable. Recent decreases in the number of HACs has
resulted in billions of dollars of savings for national healthcare expenses (AHRQ, 2015).

RECOGNIZING HOSPITAL EXCELLENCE

The most recognized award for excellence within a hospital is the Baldrige Award. The
Baldrige Health Care Criteria for Performance Excellence have been used by many
healthcare organizations to improve quality. Recipients of the Baldrige Award are
selected based on the following Criteria for Performance Excellence:

1. Leadership: How upper management leads the organization and how the organiza-
tion leads within the community.

2. Strategy: How the organization establishes and plans to implement strategic
directions.

TABLE 1.9 SELECTED HEALTHCARE SALARIES

ROLE SALARY SOURCE

CEO, Merck
Pharmaceuticals

$24.2 million www.usatoday.com/story/money/
markets/2016/08/26/drug-
money-pharma-ceos-paid-71-
more/89369152/, Retrieved September
10, 2017

Anesthesiologist Mean annual
wage $269,600

www.bls.gov/oes/current/oes291061.
htm, Retrieved September 10, 2017

General practitioner Mean annual wage
$200,810

www.bls.gov/oes/current/oes291062.
htm, Retrieved September 10, 2017

Nurse practitioner Mean annual
wage $104,610

www.bls.gov/oes/current/oes291171.
htm, Retrieved September 10, 2017

Pharmacist Median annual
wage $122,230

www.bls.gov/ooh/healthcare/
pharmacists.htm, Retrieved September
10, 2017.

Dietitian Median annual
wage $58,920

www.bls.gov/ooh/healthcare/dietitians-
and-nutritionists.htm, Retrieved
September 10, 2017.

Registered nurse Median annual
wage, $68,450

www.bls.gov/ooh/healthcare/registered-
nurses.htm, Retrieved September 10,
2017

Licensed practical
nurse

Median annual
wage$44,090

www.bls.gov/ooh/healthcare/licensed-
practical-and-licensed-vocational-
nurses.htm, Retrieved September 10,
2017.

Nursing assistant Median annual
wage $26,590

www.bls.gov/ooh/healthcare/nursing-
assistants.htm, Retrieved September
10, 2017.

1 OVERVIEW OF PATIENT SAFETY AND QUALITY OF CARE • 27

3. Customers: How the organization builds and maintains strong, lasting relationships
with customers.

4. Measurement, analysis, and knowledge management: How the organization uses
data to support key processes and manage performance.

5. Workforce: How the organization empowers and involves its workforce.
6. Operations: How the organization designs, manages, and improves key processes.
7. Results: How the organization performs in terms of customer satisfaction, finances,

human resources, supplier and partner performance, operations, governance
and social responsibility, and how the organization compares to its competitors”
(ASQ, 2017).

The Criteria for Performance Excellence is based on a set of core values. Award recipi-
ent organizations are considered to have a role-model organizational management
system that continuously makes improvements in delivering products and/or ser-
vices, demonstrates efficient and effective operations, and provides a way of engaging
and responding to customers and other stakeholders.

RECOGNIZING NURSING EXCELLENCE

The American Nurses Credentialing Center’s (ANCC, 2017) Magnet Recognition
Program awards healthcare organizations that have achieved superior performance
and is often referred to as the ultimate credential for high-quality nursing. The
Magnet Recognition Program evaluates sources of evidence that create the
foundational infrastructure for excellence, while its focus on results fosters a
culture of quality and innovation. To achieve Magnet Recognition, organizations
participate in a rigorous review process where organizations must demonstrate
support of professional clinical practice, promote excellence in the delivery of
nursing services to patients, and have processes to promote best nursing practices
(ANCC, 2017).

Similar to the Magnet Recognition Program, but not as expensive and not requir-
ing as extensive a process, is the Pathway to Excellence Program. To be nationally
recognized and designated for the Pathway to Excellence Program, a healthcare orga-
nization must meet specific practice standards, including:

1. Shared decision making
2. Leadership
3. Safety
4. Quality
5. Well-being
6. Professional development (ANCC, 2017).

Organizations earn the award by demonstrating that their practices and policies help
create a safe, positive work environment for nurses and high-quality, safe care for patients.

There are also numerous opportunities for individual credentialing, where licensed
nurses complete a specific number of education hours and/or hours of experience and
take a test to demonstrate mastery of a body of knowledge and acquired skills in a
particular specialty (McHugh et al., 2014). The ANCC, among many other organizations,
offers numerous certification for the various types of nursing care (see http://www.
nursecredentialing.org/Certification).

28 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

ROLE OF NURSE LEADERS IN ENSURING QUALITY AND
SAFETY

In 2010, the IOM released the report, The Future of Nursing: Leading Change, Advancing Health
(IOM, 2010). The key message of the report was for nurses to take a greater leadership role
across care settings in the increasingly complex U.S. healthcare system. As the population
ages and becomes increasingly diverse and to effectively respond to the changes and
complexity of healthcare, the report examines how the roles, responsibilities and education

TABLE 1.10 IOM RECOMMENDATIONS FOR THE FUTURE OF NURSING, 2010, AND 2015

IOM RECOMMENDATIONS—2010

• Remove scope of practice barriers
• Implement nurse residency programs
• Expand opportunities for nurses to lead and diffuse collaborative improvement efforts
• Double the number of nurse with a doctorate by 2020
• Build an infrastructure for collection and analysis of interprofessional healthcare

workforce data
• Increase the proportion of nurses with a baccalaureate degree to 80% by 2010
• Ensure that nurses engage in lifelong learning
• Prepare and enable nurses to lead change to advance health

IOM RECOMMENDATIONS—2015

• Build common ground with other health professions groups around scope of practice
and other issues in policy and practice

• Create and fund transition-to-practice residency programs
• Expand efforts and opportunities for interprofessional collaboration and leadership

development for nurses
• Make diversity in the nursing workforce a priority.
• Promote nurses’ pursuit of doctoral degrees
• Continue pathways toward increasing the percentage of nurses with a baccalaureate degree
• Promote nurses’ interprofessional and lifelong learning
• Promote the involvement of nurses in the redesign of care delivery and payment systems
• Improve workforce data collection
• Communicate with a wider and more diverse audience to gain broad support for

campaign objectives

Source: Institute of Medicine (IOM). (2010). The future of nursing: Leading, changing, advancing health. Retrieved from
http://nationalacademies.org/HMD/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx

NURSE LEADER AND MANAGER

RADM Jessie M. Scott, DSc, RN, FAAN, was Assistant Surgeon General in the
U.S. Public Health Service and led the Division of Nursing for 15 years. She was
instrumental in the passage and implementation of the Nurse Training Act. Her
career led her to address nursing shortages from Arkansas to Connecticut and
later to work with nursing education programs in India, Egypt, Liberia, and
Kenya. Read more about her at www.nursingworld.org/halloffame

1 OVERVIEW OF PATIENT SAFETY AND QUALITY OF CARE • 29

of nursing should change to improve healthcare for everyone. In that nurses represent the
largest segment of the healthcare workforce, the IOM recommended that nursing:

1. Be able to practice “to the full extent of their education and training
2. Improve nursing education
3. Assume leadership positions and serve as full partners in healthcare redesign and

improvement efforts
4. Improve data collection for workforce planning and policy making” (IOM, 2010)

A few years later, the IOM released a report on the progress achieved on
the IOM 2010 report recommendations (see Table 1.10), focusing on the areas of
removing barriers to practice and care; transforming education; collaborating and
leading; promoting diversity; and improving data. In this report, the IOM com-
mittee concluded that “no single profession, working alone, can meet the complex
needs of patients and communities. Nurses should continue to develop skills and
competencies in leadership and innovation and collaborate with other profession-
als in healthcare delivery and health system redesign. To continue progress on the
implementation of The Future of Nursing recommendations and to effect change in
an evolving healthcare landscape, the nursing community must build and strengthen
coalitions with stakeholders both within and outside of nursing” (IOM, 2015).

KEY CONCEPTS

1. Healthcare quality is defined as “the degree to which healthcare services for indi-
viduals and populations increase the likelihood of desired health outcomes and
are consistent with current professional knowledge” (IOM, 2001).

2. Several organizations have significant roles in influencing the quality of care and
patient safety;, for example, The ISMP, The NAM, The NQF, IHI, TJC, The Leapfrog
Group, HFMA.

3. Data from CMS Hospital Compare provide information on the quality of care
provided to patients in hospitals and includes information about patients’ experi-
ences (HCAHPS), timely & effective care, complications, readmissions and deaths,
use of medical imaging, payment and value of care.

4. There are several examples of quality care and patient safety measures that are
used primarily in healthcare organizations, such as hospitals, nursing homes, and
outpatient clinics; for example, the CMS Core Measures, AHRQ Quality Indicators,
AHRQ Patient Safety Indicators, NQF and ANA Nurse Sensitive Indicators, and
the NCQA HEDIS Measures.

5. Unwanted variation is variation in the use of medical care that cannot be explained
on the basis of illness, medical evidence, or patient preferences.

6. Transparency is considered to include reporting not only the real cost of care, but
also clearly reporting information about performance failures as well as successes
(Austin et al., 2016).

7. It has been estimated that, while hospitalized, about one in four patients experi-
ence one or more adverse events that result in a longer hospital stay, permanent
harm, the need for a life-sustaining intervention, or death. Of these adverse events
that resulted in injury, almost half were preventable (OIG, 2010).

30 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

8. Nurses are key to ensuring and improving quality of care and safety for patients
and families, as well as for the organizations in which they work.

9. Strategies to reduce unwarranted variation and ensure predictable and favorable
patient-care outcomes have proven successful in improving healthcare quality and
patient safety; for example, developing checklists and other standardized tools,
using best practices, working in an organization with a culture of safety, and com-
munication when an error does occur.

10. Standardized communication tools such as the SBAR technique and using stan-
dardized order sets, protocols, and other best practices can be used by nurses and
other members of the healthcare team to prevent errors, ensure quality care, and
reduce variability in patient care and the potential for error.

11. The term “sharp end” has been used to identify the important and significant direct
contact role that nurses at the bedside, closest to clinical activities, play in recognizing
the need for and potential impact of practice changes. Nurses may see the sharp end
effects on patients and others first when the right care is not provided. Front line clini-
cal nurses (as well as nurses in formal leadership positions) often assume leadership
at the “sharp end” of care in direct contact with patients to ensure safety and quality.

12. Workarounds may occur when something doesn’t work well while nurses are
providing care to a patient and they work around the “normal” way of doing
things. These workarounds increase the opportunities for inconsistent care and
inconsistent outcomes.

13. Even though some may consider the United States as the leader in healthcare or
in efforts to improve healthcare quality and patient safety, comparative studies
by the OECD, the United Kingdom, and The Commonwealth Fund, among oth-
ers, have consistently found that the United States does not have better health-
care outcomes than other industrialized nations, including countries in Europe,
Australia, Canada, and New Zealand (The Commonwealth Fund, 2014; The
Health Foundation, 2015; OECD, 2017).

14. Poor U.S. healthcare outcomes do not make sense when you consider the fact that
year after year, the United States continues to spend more on healthcare (per cap-
ita), than any other country in the world (OECD, 2017).

15. Higher U.S. spending appears to be largely driven by greater use and cost of medi-
cal technology and higher drug and healthcare prices, rather than by more fre-
quent doctor visits or hospital admissions.

16. Despite spending more on healthcare, Americans have poor health outcomes,
including shorter life expectancy, greater prevalence of chronic conditions, and
higher infant mortality rates (The Commonwealth Fund, 2017).

17. The U.S.-based Joint Commission has an international component that has estab-
lished the International Patient Safety Goals that are used worldwide.

18. The majority of hospitals in the United States (AHA, 2017) are required by the CMS to
meet TJC accreditation requirements to be reimbursed for care received by Medicare
and Medicaid beneficiaries, who represent the majority of hospitalized patients.

19. There are over 4,000 hospitals and approximately 77% of them are currently
accredited by TJC (TJC, 2017).

20. The CEO of Merck Pharmaceuticals has an annual salary of $24.2 million.
21. The Baldrige Health Care Criteria for Performance Excellence has been used by

many healthcare organizations to improve quality.
22. ANCC Magnet Recognition Program awards healthcare organizations that have

achieved superior performance and is often referred to as the ultimate credential
for high-quality nursing.

1 OVERVIEW OF PATIENT SAFETY AND QUALITY OF CARE • 31

KEY TERMS

Adverse event
Errors
Healthcare quality
High-quality care

Sentinel events
Sharp end
Transparency

REVIEW QUESTIONS

1. A group of emergency department nurses are asked to develop an action plan to
improve the time before patients who present with chest pain receive an ECG. Which
of the following would not be helpful when working on a QI effort like this?

A. Identify an interprofessional group of individuals to help review current
performance.

B. Compare current hospital emergency department data results to benchmark
comparison information reported on a national website.

C. Post current hospital performance data results openly to staff in the nursing
lounge.

D. Identify whose fault it is that results are not very good.

2. As a staff nurse you are interested in making QIs in the overall care of patients
with heart failure. Where would be most helpful to look for data and information
to help you get started with these improvements?

A. Explore the IHI website (www.IHI.org), which includes white papers,
evidence-based protocols, blogs, and improvement stories that can be applied
to patients with heart failure.

B. Review the National Cancer Institute’s website, which includes facts
and statistics related to cancer care, resources, and latest research
developments.

C. Review drug companies’ websites to see if there are any new medications
available to treat heart failure.

D. Google “heart failure” to see if you can get access to the latest treatment
options for this patient population.

3. An 87-year-old patient was admitted to an acute care hospital. The patient was
in a severe automobile vehicle accident. He is unconscious in intensive care and
on a ventilator. On Day 3 of the patient’s hospitalization, the patient experiences
a cardiac arrest and a code blue is called. The code blue lasts for an hour. The
patient’s heart rhythm is restored. When the family is notified of the event, the
wife is very upset. She states she had provided the hospital with the patient’s
advance directive, which clearly stated the patient should not be resuscitated. You
are the nurse talking to the wife. What do you do?

A. Apologize, but state that the patient was a full code, which means he must be
resuscitated.

B. Apologize, and assure the wife that you will be contacting the attending
physician and your nurse manager that the problem occurred. The risk
management department will probably review this case.

32 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

C. Notify the wife that the advance directive is not legal or binding and that
the wife needed to tell them specifically that the patient did not want to be
resuscitated.

D. Tell the wife to try to focus on the positive, that her 87-year-old husband is
still alive.

4. A patient asks a nurse what it means to have a hospital accredited by TJC. Which
one of the following is not a Joint Commission quality compliance requirement?

A. Billing models
B. Core measures
C. Safe practice measures
D. Process improvement efforts

5. A patient read that hospitals are not getting reimbursed by the CMS for certain
never events and asks a nurse to explain. Which one of the following is an example
of a never event?

A. Absence of a hospice unit within the hospital
B. Emergency department admissions of over 1,000 per month
C. Nursing stations located at the end of the hall versus in the middle of the

patient-care unit
D. Stage IV hospital-acquired pressure ulcer

6. What is a common cause of errors within healthcare settings?

A. Uncaring professionals
B. Incompetent caregivers
C. Communication problems between caregivers
D. Phones not connecting to the nurse’s station

7. QSEN has developed multiple quality and safety competencies to guide
nursing practice. Identify which of these are considered a part of the six key
competencies.

A. QI, teamwork and collaboration, and EBP
B. Fact finding, mission statements, and strategic planning
C. Stakeholder feedback, budget reconciliation, and strategic planning
D. Financial reporting, wait time measurements, and time delays in getting

treatments

8. You are the nurse caring for a patient who was recently told he has heart failure.
The patient will be relocating next week to a different state. The patient has a pri-
mary care provider in his new state and intends to follow up as instructed upon
discharge. However, he would like to identify an acute care hospital in his new
state that is adept in caring for heart failure patients, in the event that he needs
to be admitted. The patient asks for your recommendation. All of the suggestions
below may give him good information. What would be your best suggestion to the
patient so that he may make a well-informed, objective decision?

A. Tell the patient that hospitals publicly report their quality data associated
with caring for heart failure patients on a website and instruct him where he
can retrieve this information.

1 OVERVIEW OF PATIENT SAFETY AND QUALITY OF CARE • 33

B. Tell him to ask members in the community or family and friends where they
have had good experiences.

C. Tell him to ask his primary care provider for a recommendation.
D. Tell him to visit the websites of hospitals in the community where he is moving.

9. You are an administrator working in an urban health system. You have been
charged to lead the efforts of redesigning the patient-care delivery model. This
model is intended to best represent patient expectations. As such, in developing
the model, you recognize the importance of taking into account the patient’s qual-
ity concerns. Which answer best represents the top patient quality concerns as
described by the HFMA Value Project (2011)?

A. Access: Make care available and affordable. Safety: Do not hurt me.
Outcomes: Make me better. Respect: Respect me as a person, not a case.

B. Access: Make care available and affordable. Safety: Do not hurt me.
Quality: Provide high-quality care. Respect: Respect me as a person,
not a case.

C. Safety: Do not hurt me. Outcomes: Make me better. Value: Deliver care at a
reasonable price. Inclusion: Include my loved ones in any care plans.

D. Safety: Do not hurt me. Quality: Provide high-quality care. Value: Deliver
care at a reasonable price. Respect: Respect me as a person, not a case.

QSEN ACTIVITIES

1. Go to the QSEN website (www.qsen.org) and search for Quality. Click on
Quality Improvement (www.homehealthquality.org/Education/Best-Practices.
aspx). Work on Cardiovascular Health Part 1 (www.homehealthquality.org/
Education/Best-Practices/BPIPs/Cardiovascular-Health-Part-1-BPIP.aspx). Can
this information help improve patient safety?

2. Go to the QSEN website (www.qsen.org) and search for Quality. Click on Quality
Improvement (www.homehealthquality.org/Education/Best-Practices.aspx). Work
on Cardiovascular Health Part 2. Can this information help improve patient safety?

REVIEW ACTIVITIES

1. Go to the QSEN Institute website, qsen.org. Click on Competencies, Pre-Licensure.
Also, click on Teaching Strategies. What did you find at these sites that apply to you
as a student?

2. What patient safety challenges do you see in hospitals or in outpatient care sites?
3. Read through the summary of recommendations for two reports in the Quality

Chasm series (go to www.nap.edu/catalog/21895/quality-chasm-series-health-
care-quality-reports), and look at the list of recommendations. Of these recommen-
dations, what surprised you?

CRITICAL DISCUSSION POINTS

1. Are all adverse events inevitable?
2. How is the FDA involved in improving patient safety?

34 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

3. Do sentinel events have to be reported to TJC?
4. Are there similarities in the measures of patient safety and the measures of quality

of care (Table 1.3)?
5. Should only events that harm patients be reported to external quality and safety

organizations?
6. Are patients safer if they stay in the hospital longer?
7. Name three of the QSEN competencies.
8. Does blaming a nurse for an error improve patient safety?
9. Name the six aims of the healthcare system from the IOM Crossing the Quality

Chasm 2001 report.
10. Is improving quality and patient safety expensive?

EXPLORING THE WEB

1. AHRQ—www.ahrq.gov
2. ANCC—www.nurscredentialing.org
3. Baldrige Foundation—www.baldrigefoundation.org
4. CMS—www.cms.gov
5. FDA—www.fda.gov
6. IHI—www.ihi.org
7. NQF—www.qualityforum.org
8. QSEN Institute—qsen.org
9. Quality Chasm Series—www.nap.edu/catalog/21895/quality-chasm-series-health-

care-quality-reports?gclid=EAIaIQobChMIjIeh35-31QIVBoNpCh2y0ASvEAAYASA
AEgIhY_D_BwE

10. TJC—www.jointcommission.org
11. U.S. News and World Report ratings of hospitals—health.usnews.com/best-

hospitals/rankings

EVIDENCE FROM THE LITERATURE

Citation: The Economist. (2018). Land of the free-for-all: America is a health-care
outlier in the developed world. Retrieved from www.economist.com/news/
special-report/21740871-only-large-rich-country-without-universal-health-
care-america-health-care-outlier

DISCUSSION

America has some of the best hospitals in the world but it is also the only large
rich country without universal healthcare coverage. About half of Americans
have their health insurance provided by their employers. Healthcare costs can
be financially ruinous for others. In 2016, America spent $10,348 per person on
healthcare, roughly twice as much as the average for comparably rich countries.
On average, both hospital cost and drug prices can be 60% higher than in Europe.
The American Affordable Care Act expanded the health insurance system and
cut the number of uninsured people from 44 million to 28 million but still left a
gap among people not poor enough to qualify for Medicaid but not rich enough
to buy private insurance.

1 OVERVIEW OF PATIENT SAFETY AND QUALITY OF CARE • 35

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SUGGESTED READINGS

Dekker, S. (2011). Patient safety: A human factors approach. Boca Raton, FL: CRC Press.
Gawande, A. (2011). The checklist manifesto: How to get things right. New York, NY: Picador.
Haviley, C., Anderson, A., & Currier, A. (2014). Overview of patient safety and quality of care.

In Kelly, P., Vottero, B., & McAuliffe, C. (2014). Introduction to quality and safety education for
nurses: Core competencies. New York, NY: Springer.

Hughes, R. G. (Ed.) (2008). Patient safety and quality. An evidence-based handbook for nurses. Rock-
ville, MD: U.S. Agency for Healthcare Research and Quality (US).

Institute of Medicine (IOM). (2001). In Kohn L. T., Corrigan J. M., & Donaldson M. S. (Eds.),
To err Is Human: Building a safer health system. Washington, DC: National Academy Press.
Retrieved from https://www.nap.edu/read/9728/chapter/1

Institute of Medicine (IOM). (2001). Crossing the quality chasm: A new health system for the 21st century.
Retrieved from https://www.nap.edu/catalog/10027/crossing-the-quality-chasm-a-new-
health-system-for-the

Institute of Medicine (IOM). (2004). Keeping patients safe: Transforming the work environment of
nurses. Washington, DC: National Academy Press. Retrieved from https://www.nap.edu/
catalog/10851/keeping-patients-safe-transforming-the-work-environment-of-nurses

Institute of Medicine (IOM). (2010). The future of nursing: Leading, changing, advancing health.
Retrieved from http://iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-
Advancing-Health.aspx

The Commonwealth Fund. (2015). 2015 international profiles of health care systems: Australia,
Canada, China, Denmark, England, France, Germany, India, Israel, Italy, Japan, The Netherlands,
New Zealand, Norway, Singapore, Sweden, Switzerland, and the United States. Mossialos E.,
Wenzl M., Osborn R., & Sarnak D., D (Eds.), The Commonwealth Fund, Pub No. 1857.

The Joint Commission (TJC). (2017). Initiatives. 5 million lives campaign. Retrieved from http://
www.ihi.org/Engage/Initiatives/Completed/5MillionLivesCampaign/Pages/default.aspx

The Joint Commission (TJC). (2017). Initiatives. The IHI triple aim initiative. Retrieved from http://
www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx

The Joint Commission (TJC). (2017). Sentinel event policy and procedures. Retrieved from https://
www.jointcommission.org/sentinel_event_policy_and_procedures/

Lee, D. S., & Mir, H. R. (2014, October). Global systems of health care and trauma. Journal of
Orthopedic Trauma, 28(Suppl. 10), S8–S10, doi:10.1097/BOT.0000000000000213.

Wachter, R. M. (2012). Understanding patient safety (2nd ed.). New York, NY: McGraw-Hill.

Upon completion of this chapter, the reader should be able to

1. Review a brief history of the Quality and Safety Education for Nurses (QSEN)
initiative in the United States.

2. Discuss the various phases of development of the QSEN initiative.

3. Identify the six QSEN competencies, which are patient-centered care (PCC),
quality improvement (QI), safety, teamwork and collaboration, evidence-
based practice (EBP), and informatics.

4. Identify the knowledge, skills, and attitudes (KSAs) associated with each of
the six QSEN competencies.

5. Identify QSEN competencies related to accreditation standards for nursing
programs.

6. Recognize resources available for further learning about QSEN competencies.

7. Discuss special issues of nursing journals that have focused on QSEN.

2
QUALITY AND SAFETY EDUCATION
FOR NURSES

Catherine C. Alexander, Gail Armstrong, and Amy J. Barton

One goal of QSEN is to alter nursing’s professional identity so that when we think of what it means to be
a respected nurse, we think not only of caring, knowledge, honesty, and integrity. But also, that it means
that we value, possess, and collectively support the development of quality and safety competencies.
(Cronenwett, 2007)

40 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

A
n 86-year-old woman fell at home and suffered an intertrochanteric hip fracture. She
will have a plate and screws surgically placed to stabilize the fracture. This patient has
a past medical history of osteoporosis and atrial fibrillation. The patient takes Fosamax
(alendronate sodium) 70 mg by mouth once a week and Coumadin (warfarin) 3 mg by

mouth once a day. She proceeds to surgery without any member of the healthcare team checking
her last dose of Coumadin or her international normalized ratio (INR) level. During surgery, the
patient begins to bleed profusely and requires a transfusion of 5 units of packed red blood cells.
The patient is transferred to the ICU for further monitoring. After this transfer, the interprofessional
healthcare team gathers to review elements of this case (see Figure 2.1).

1. Which members of the interprofessional healthcare team should be present to review this
case?

2. How was patient safety and quality compromised in this case?
3. Which processes of patient care might be reviewed to ensure that this type of error does

not occur again?

The national nursing initiative, Quality and Safety Education for Nurses (QSEN), funded by the Robert
Wood Johnson Foundation, has trained over 1,000 nursing faculty throughout the United States in
how to build quality and safety content in prelicensure nursing curricula through education workshops
sponsored by the American Association of Colleges of Nursing (AACN). In 2016, QSEN sponsored
an international task force to guide the integration of the QSEN competencies in several countries
across the globe (Canada, South Korea, Taiwan, Germany, and Sweden). The QSEN competencies
are now translated into Spanish and can be found on the QSEN website (www.qsen.org). Plans are
in place to translate the competencies into Chinese, Korean, and Swedish. Both faculty and students

will find that the QSEN website (www.qsen.org) is a rich resource
for ongoing education related to quality and safety.

This chapter outlines a brief history of QSEN, discusses the
four phases of development of the QSEN initiative, and reviews
the six QSEN competencies, that is, safety, informatics, patient-
centered care (PCC), quality improvement (QI), teamwork
and collaboration, and evidence-based practice (EBP). Built
into each QSEN competency are the knowledge, skills and
attitudes (KSAs) associated with each QSEN competency. The
chapter then identifies how the QSEN KSAs are integrated
into various phases of a nursing curriculum. The chapter also
connects the QSEN competencies to accreditation standards
for nursing programs. Finally, the chapter discusses nursing
journals that have published QSEN-specific supplements
and resources available for further learning about the QSEN
competencies.

HISTORY OF QSEN INITIATIVES IN THE UNITED STATES

Educating the next generation of nurses in quality and safety is the overarching goal of
the QSEN organization. To understand QSEN’s history, one must go back to 1999. Since
the Institute of Medicine (IOM, 1999) report, To Err Is Human: Building a Safer Health Care
System, which estimated 98,000 lives were lost yearly in hospitals due to preventable

FIGURE 2.1 Interprofessional
activities at the University of
Colorado.

2 QUALITY AND SAFETY EDUCATION FOR NURSES • 41

medical error, a new era of consciousness about quality and safety in the U.S. healthcare
system took root. Since the IOM report was published, healthcare leaders in both aca-
demia and practice have worked diligently to repair our fragmented healthcare system.
However, progress has been slow since the report was issued. In 2015, The National
Patient Safety Foundation (NPSF) convened an expert panel that concluded that despite
advances in patient safety over the last 15 years, patients continue to experience harm
that could be prevented (NPSF, 2015). In a report issued by Makary and Michael (2016),
it was noted that medical errors are now the third leading cause of death, estimating
252,454 people lose their lives annually because of medical error.

Why are so many lives being lost to medical errors and what steps must be taken
to fix the problem? Preventable deaths are linked to human factors including poor
communication among providers, fatigue, time pressure, and systems breakdowns
(Wachter, 2010). The NPSF acknowledges that our current healthcare system is far
more complex than was previously understood and recommends that we rethink
safety based on “systems thinking.”

Dolansky and Moore (2013) define systems thinking as “the ability to recognize,
understand and synthesize the interactions and interdependencies in a set of compo-
nents designed for a specific purpose and understand how the components of a com-
plex healthcare system influence the care of an individual patient” (p. 2). Healthcare
leaders have a large role to play in providing safe, high-quality care. The NPSF report
states “leaders must shift from a reactive approach to patient safety to one that consis-
tently prioritizes a safety culture that includes the well-being and safety of the work-
force” (NPSF executive summary, 2015). To accomplish this, leaders must be focused
on patient safety at every level of an organization and, in particular, at the frontline
of care. The American Organization of Nurse Executives (AONE) Guiding Principles docu-
ment (2007) supports the following four patient safety goals: change from a culture of
blame to one that is focused on teamwork, develop a leadership model that embraces
shared decision making rather than the top down leadership style found in many
hierarchical organizational structures, enhance collaboration within and external to
the organization, and develop leadership competencies that are patient-centered and
focused on patient safety.

Since the 1999 report, To Err Is Human, several subsequent reports have been pub-
lished by the Institute of Health that address the causes of the startling number of
preventable deaths in the acute care setting. The 2001 IOM report, Crossing the Quality
Chasm, identified the need for safe, timely, efficient, equitable, effective, and patient-
centered healthcare goals. The acronym STEEEP is often used as a mnemonic for these
goals (IOM, 2001; Table 2.1).

In 2003, the IOM published Health Professions Education: A Bridge to Quality focused
on the importance of all health professions students being educated in how to deliver
care that exhibits qualities of patient-centeredness, QI, teamwork and collaboration,
evidence-based practice (EBP), and informatics. The 2010 IOM report, The Future of
Nursing, Leading Change, Advancing Health, called on nursing to lead the quality and
safety movement. The report cited that nurses are in a unique position to impact the
safety movement in the United States. However, there is a critical need to reassess
nursing educational models that thread quality and safety throughout nursing curri-
cula at the undergraduate, graduate, and doctoral levels. This reassessment is needed
for nurses to lead QI initiatives at all levels of a healthcare organization. In 2015, a
follow-up report by the IOM, Assessing Progress on the Institute of Medicine Report—The
Future of Nursing, acknowledged that nursing had made significant strides in meeting
many of the 2010 recommendations, but there is more work to do if nursing is going
to lead collaborative improvement efforts through interprofessional teams. A pressing

42 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

question is how to engage healthcare professionals and frontline staff in QI “at the
sharp end of the healthcare delivery system” where a patient’s healthcare needs are
met (Nelson, Batalden, & Godfry, 2007, p. 6).

The term “sharp end” has been used to identify the point in a healthcare system
where providers, for example, nurses, physicians, aides, and so on, work and give
care to patients. This point or sharp end of patient care is where errors may occur
(Reason, 1990). Errors on the sharp end of patient care have often been considered to
be the result of provider deficiencies such as careless behavior or lack of knowledge or
skill. In fact, these sharp end errors have now been recognized to often be the result of
organizational and extra-organizational issues, referred to as latent issues in a health-
care system. These latent issues can be caused by healthcare system organization and
management factors (Vincent, 2006), as well as by healthcare regulators, payers, insur-
ance administrators, economic policymakers, and technology suppliers. All of these
latent end issues affect the behavior of providers at the sharp end point of service with
patients and may lead to patient-care errors.

PHASES OF DEVELOPMENT OF THE QSEN INITIATIVE

A group of nurse leaders, who had collaborated yearly since 1993 at an interprofessional
conference with physicians and healthcare administrators, met to explore the impact of
the 2003 IOM report, Health Profession Education: A Bridge to Quality, on health profes-
sions education. Engaging with other national thought leaders in nursing, this influential
group asked the question: “What teaching strategies will prepare graduates in the health
professions with the necessary skills to continuously improve the quality and safety of
the healthcare system in which they work?” This question challenged this interprofes-
sional group to outline a new curriculum that incorporates the principles of patient-
centeredness, QI, teamwork and collaboration, EBP, and informatics outlined in the 2003
IOM report Health Professions Education: A Bridge to Quality. During the same period of
time, the first phase of the Quality and Safety for Nurses (QSEN) initiative began with
funding by the RWJF. The overall goal was to prepare nurses with the KSAs required to

TABLE 2.1 INSTITUTE OF MEDICINE’S (IOM) DEFINITIONS OF STEEEP

IOM TERM DEFINITION

S Safe Avoiding injuries to patients from the care that is intended to help
them

T Timely Reducing waits and sometimes harmful delays for both those who
receive and those who give care

E Efficient Avoiding waste, including waste of equipment, supplies, ideas,
and energy

E Equitable Providing care that does not vary in quality because of personal
characteristics such as gender, ethnicity, geographic location,
and socioeconomic status

E Effective Providing services based on scientific knowledge to all who could
benefit, and refraining from providing services to those not likely
to benefit

P Patient-
centered

Providing care that is respectful of and responsive to individual
patient preferences, needs, and values, and ensuring that
patient values guide all clinical decisions

Source: STEEEP Healthcare Goals. Compiled with information from the report, IOM. (2001). Crossing the quality chasm:
A new health care system for the 21st century. Washington, DC: National Academies Press.

2 QUALITY AND SAFETY EDUCATION FOR NURSES • 43

improve quality and safety in healthcare systems (Cronenwett et al., 2007). At the time,
safety and high reliability consciousness were rising as critical components for the
delivery of safe patient care. The QSEN Advisory Board decided to add safety apart
from QI as the sixth competency. Cronenwett (2007) explains the QSEN Advisory
Board’s decision to add safety as a sixth competency this way: “The culture of nurs-
ing education was about preparing a competent, safe nurse and safety was viewed as
a component of the individual professional rather than the system and we needed to
make clear that preparation for future nurses needed to include that aspect of prepar-
ing for safety as well.”

From 2005 to 2012 three phases of the QSEN initiatives were written that defined
the quality and safety competencies that would be integrated into nursing programs
throughout the United States. In Phase I, QSEN faculty outlined the KSAs appropriate
for prelicensure education for each of the six competencies (Cronenwett et al., 2007).
KSAs are defined as knowledge: the mental skills required to complete a task and the
theoretical understanding of a subject; skill: the “hands on” or physical skills that one
applies to his or her work, the proficiency or observable competence that is acquired
or developed through education, and experience; and attitude: a behavior or point of
view and the way a person views or responds to people or an experience. The KSAs
for the six competencies can be found on the QSEN website (www.qsen.org). Phases
II and III focused on faculty education and development and Phase IV, which began
in 2012, expanded the competencies at the graduate level. Today, QSEN is a vibrant
national initiative for nurses and nursing educators that offers resources for integrat-
ing the IOM’s recommendations into models of nursing education both in prelicensure
and graduate nursing education.

Phase I

Early QSEN data indicated that no nursing graduates were entering practice with
updated knowledge about safe systems or knowledge from safety science. Safety
science uses scientific methods and theoretical frameworks to achieve a trustworthy
system of healthcare delivery. Safety science helps to describe how safety errors and
near misses are recognized and reported, ways to manage human factors that impact
safe healthcare delivery, and the competencies required for health professionals to
provide safe care. Safety science has its roots in high-performance industries such as
aviation and nuclear power and has now been adapted for use in healthcare. Safety
science uses processes such as checklists and web-based reporting systems to improve
care. Safety science has two important goals: It is the personal responsibility of all
healthcare workers to both prevent errors and to continuously improve the delivery of
healthcare services for both patients and staff.

Phase II

QSEN’s Phase II work, also funded by the RWJF, occurred between 2007 and 2009 and
focused on developing a QSEN Pilot School Learning Collaborative for faculty devel-
opment. Fifteen nursing programs were selected to experiment with various peda-
gogical teaching strategies. The goal of this pilot program was to integrate the KASs,
using the five competencies cited in the IOM 2003 report (i.e., PCC, QI, teamwork and
collaboration, EBP, and informatics). Safety was added as the sixth competency given
nursing’s impact on patient outcomes at the frontline of care.

44 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

Phase III

QSEN’s Phase III work occurred between 2009 and 2012, again funded by the RWJF.
Phase III had three goals:

• Promote the ongoing development and evaluation of methods to assess student
learning of KSAs of the six QSEN competencies and disseminate the new knowledge.

• Develop the faculty expertise necessary to assist the learning and assessment of
achievement of quality and safety competencies in all types of nursing programs.

• Create a mechanism to sustain the will to change among all nursing education
programs.

The focus of the Phase III work was to begin to change the content in nursing text-
books, accreditation certification standards, licensure exams, and continued competence
requirements. Through the QSEN Phase III work, faculty from across the country were
trained in how to integrate updated quality and safety concepts into their nursing edu-
cation programs.

Phase IV

In 2012, the Tri-Council for Nursing, an alliance of four nursing organizations (i.e., the
American Association of Colleges of Nursing [AACN], National League for Nursing
[NLN], American Nurses Association [ANA], and American Association of Nurse
Executives [AONE]) expanded the QSEN competencies at the graduate level. With sup-
port from the RWJF, the four nursing organizations led the $4.3 million effort to advance
state and regional strategies to create a more highly educated workforce.

Integration of the KSAs Into Nursing Curricula

For practicing nurses, it is helpful to understand how nursing education is changing
and to consider how QSEN KSAs are integrated into nursing curricula. Incorporating
QSEN into a nursing curriculum requires an understanding of the six QSEN compe-
tency definitions of PCC, QI, teamwork and collaboration, EBP, informatics, and safety
that are available on the QSEN website. Incorporating QSEN into a curriculum also
requires a clear sense of how to effectively place the 162 KSA elements that operational-
ize those six QSEN competencies into a nursing curriculum. To provide guidance to fac-
ulty, a modified Delphi research strategy was used. The Delphi research strategy is an
interactive forecasting method that allowed a panel of experts to gain consensus about
where individual KSAs should be introduced in the nursing curriculum and where
they should be emphasized (Barton, Armstrong, Preheim, Gelmon, & Andrus, 2009).

Each of the KSAs were identified as appropriate for introduction and emphasis
either in a beginning-level nursing course, an intermediate-level nursing course, or an
advanced-level nursing course. A beginning-level nursing course is one of a student’s
first nursing education courses. An intermediate-level nursing course is taken in the mid-
dle of a student’s nursing education program. And an advanced-level nursing course is
taken by a student just before graduation. The KSAs of the six QSEN competencies pro-
vide a strong foundation for quality and safety practices at the undergraduate level. The
work of QSEN has only evolved over the last decade and many current nursing students
will likely work with nurse preceptors who are not aware of the six competencies.

Table 2.2 provides a summary table of the Delphi results, indicating where KSAs
from five of the six QSEN competencies should be introduced and where they should

TABLE 2.2 OVERVIEW OF DELPHI STUDY FINDINGS

QSEN
COMPETENCY

BEGINNING
INTRODUCTION

INTERMEDIATE
INTRODUCTION

ADVANCED
INTRODUCTION

BEGINNING
EMPHASIS

INTERMEDIATE
EMPHASIS

ADVANCED
EMPHASIS

PCC KSA
competencies

KSA
competencies

Teamwork and
collaboration

Skill and attitude
competencies

Knowledge
and skill
competencies

Attitude
competencies

Knowledge
and skill
competencies

EBP Knowledge
and attitude
competencies

Skill
competencies

Knowledge
and attitude
competencies

Skill and
attitude
competencies

Safety KSA
competencies

Attitude
competencies

KSA
competencies

Knowledge
competencies

Informatics Skill and attitude
competencies

Knowledge
competencies

Skills
competencies

Knowledge
and attitude
competencies

QI Attitude
competencies

Skill and attitude
competencies

Knowledge
competencies

Attitude
competencies

KSA
competencies

EBP, evidence-based practice; KSA, knowledge, skill, and attitude; PCC, patient-centered care; QI, quality improvement; QSEN, Quality and Safety Education for Nurses.

Source: Compiled with information from Barton, A. J., Armstrong, G., Preheim, G., Gelmon, S. B., & Andrus, L. C. (2009). A national Delphi to determine developmental progression of quality
and safety competencies in nursing education. Nursing Outlook, 57(6), 313–322.

45

46 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

be emphasized in a prelicensure nursing curriculum. Most interesting of these Delphi
results is the clear message that all six quality and safety competencies need to be
introduced and emphasized throughout a prelicensure nursing student’s education
program.

THE SIX QSEN COMPETENCIES

PCC

PCC emphasizes recognition of the patient or designee as the source of control and
full partner in providing compassionate and coordinated care based on respect for the
patient’s preferences, values, and needs. For example, KSAs for this PCC competency
are the following:

• K—Integrate understanding of the multiple dimensions of PCC: Patient/family/
community preferences and values; coordination and integration of care; infor-
mation, communication, and education; physical comfort and emotional support;
involvement of family and friends; transition; and continuity.

• S—Elicit patient values, preferences, and expressed needs as part of clinical inter-
view; implementation of the care plan; and evaluation of care.

• A—Value seeing healthcare situations through the patient’s eyes (Cronenwett
et al., 2007).

The KSAs for PCC allow for not only the basic needs of the patient to be met (bath-
ing, feeding, toileting) but they also allow for the basic needs to be met in a way that
considers patient preferences and values in the delivery of care. For example, when
would the patient like to be bathed? How does he or she like to be fed? What aspects
of the care is the patient able to carry out that they would prefer to do independently
of the nurse? Do family members want to be active participants in their loved one’s

You are the charge nurse on a medical–surgical unit. A new graduate nurse is car-
ing for a complex patient who has been hospitalized for over 2 weeks. The patient
and the family have expressed frustration and mistrust in the healthcare team
because of poor communication among members of the team. An individualized
care plan was developed based on the unique needs of the patient. After report,
you ask the new graduate nurse to read the plan of care for specific instructions
related to the physical and psychosocial needs of the patient. The nurse states
“I don’t have time to read the plan of care, I have to pass my medications. I will
read it later.” Reading the plan of care later in the shift does not allow the nurse
to consider the patient’s preferences, values, or needs and may compromise the
delivery of patient-centered care.

1. Which (QSEN) competency would help you in expanding the nurse’s practice?
2. Which resources for this QSEN competency might help you in working with this

nurse?
3. Describe leadership attributes that would have helped this nurse provide PCC.

CASE STUDY 2.1

2 QUALITY AND SAFETY EDUCATION FOR NURSES • 47

care? Physical comfort and emotional support are one knowledge aspect of the larger
PCC competency. A report by the Picker Institute and the Commonwealth Fund titled
Patient-Centered Care: What Does It Take? provides the contemporary context for PCC
(Shaller, 2009). Table 2.3 offers learning activities for PCC at the beginning, intermedi-
ate, and advanced levels of nursing education.

Teamwork and Collaboration

The QSEN competency of teamwork and collaboration emphasizes healthcare pro-
viders functioning effectively within nursing and interprofessional teams, fostering
open communication, mutual respect, and shared decision making to achieve quality
patient care. Examples of KSAs in this competency include the following:

• K—Describe scope of practice and roles of healthcare team members.
• S—Engage in appropriate handoff communication during shift report, patient-

care rounds, discharge, or interfacility transfer.
• A—Value the personal contribution that team members make to achieve effective

team functioning.

TABLE 2.3 PATIENT-CENTERED CARE LEARNING ACTIVITIES

CURRICULUM
LEVEL LEARNING ACTIVITIES

Beginning
level

Interview a patient about his or her diagnosis. What does the diagnosis
mean to the patient? How does the patient’s perspective of the
diagnosis differ from that of the healthcare team? Write up your
understanding of the patient’s perspective and share it with the patient.
Ask the patient for feedback about accuracy and interpretation.

Intermediate
level

Are there barriers in your practice environment to actively involve families in
patients’ healthcare processes? Examine system barriers like limited visiting
hours in the ICU or inability of family to be present in the perioperative
setting. Are there policies that interfere with family involvement? What is the
history of these policies? Do they still make sense?

Advanced
level

Sometimes the nurse must initiate a conversation about patient-centered
care. Use the following resource to identify effective strategies for
such conversations: Toolkit: Conversations on Patient-Centered Care
(https://www.orpca.org/files/Toolkit_Conversations_about_Pt_Ctrd_
Care.pdf)

CRITICAL THINKING 2.1

The video in which Donald Berwick shares his view of PCC: www.youtube.com/
watch?v=SSauhroFTpk

1. Why is “indignity” promulgated and tolerated within healthcare
institutions?

2. How can families be more authentically included in a patient-care
experience?

3. Identify three concrete actions you can take to honor the concept of patient
centeredness.

48 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

TABLE 2.4 TEAMWORK AND COLLABORATION LEARNING ACTIVITIES

CURRICULUM
LEVEL LEARNING ACTIVITIES

Beginning
level

Explore the tools recommended for healthcare teams in
the TeamSTEPPS program. These tools can be found at
www.teamstepps.ahrq.gov. Which TeamSTEPPS communication
strategies would be helpful for patient care on your unit?

Intermediate
level

Teamwork and collaboration are core elements of surgical care
processes. The IHI launched a national campaign to standardize
aspects of perioperative teamwork and collaboration. Go to IHI’s
home page at www.ihi.org. Use the search box and type in SCIP.
Look at the elements of the SCIP Project. What components of the
SCIP Project are present in your perioperative services?

Advanced
level

Review the article by Neily et al. (2010) and examine the implications of
these authors’ findings on training healthcare teams. Note the impact
of teamwork training on patient outcomes. The first author on this
research article is a nurse.

IHI, Institute for Healthcare Improvement; SCIP, Surgical Care Improvement Project.

Emma, a new graduate, just completed her 3-month orientation. She is given a com-
plex patient assignment without the assistance of a preceptor. After receiving a quick
bedside report from the night nurse, Emma notices that her patient is restless and has
an elevated respiratory rate. She is concerned, but realizes her patient is not wearing
his oxygen. She puts the nasal cannula on the patient and tells him she will be back
to check on him. Emma is starting to get behind in her work, but she wants to make a
good impression with her colleagues and decides not to ask for help. One hour later,
the nursing assistant tells Emma that her patient is in respiratory distress. Emma
checks on her patient and decides to ask the charge nurse for help. After assessing
the patient, the charge nurse calls the interprofessional rapid response team and tells
Emma to bring the crash cart into the room. When the team arrives, they decide the
patient is unstable and must be transferred to the ICU for close monitoring.

1. What critical steps should Emma have taken to engage the interprofessional team
sooner?

2. Describe the places where teamwork and communication could have been strength-
ened in this case.

3. Identify the quality and safety issues that emerged around teamwork and collabora-
tion. What actions could have been taken to prevent a patient transfer to the ICU.

4. Describe one leadership concept that would have been beneficial for Emma to use to
speak up and ask for help?

CASE STUDY 2.2

Students begin to value the nurse’s role in planning care and the nurse’s impact on
patient outcomes when the nursing scope of practice is learned within the context
of interprofessional teams. Teamwork is one of the core competencies, along with
communication, roles and responsibilities, and ethics, that all health professions
students should achieve. The nurse is often at the center of communication for the
healthcare team and frequently facilitates important patient-care transitions. For

2 QUALITY AND SAFETY EDUCATION FOR NURSES • 49

example, communication of the patient’s changing status is vital to successful use
of rapid response teams. Rapid response teams are a group of individuals from a
variety of disciplines such as nursing, medicine, and respiratory therapy that use
evidence-based interventions in the acute care setting to provide timely, focused
care for patients experiencing rapid deterioration. The Institute for Healthcare
Improvement’s (IHI) 5 Million Lives Campaign (2006) facilitated widespread adop-
tion of this team-based intervention. Details about rapid response teams can
be explored at IHI’s website (go to www.ihi.org and search for rapid response
teams). Table 2.4 offers learning activities that focus on the teamwork and collabo-
ration competency at the beginning, intermediate, and advanced levels of nursing
education.

Evidence-Based Practice

Nurses play a key role in protecting patients from harm by providing high-quality
healthcare (Balakas & Smith, 2016). Research indicates that the implementation of EBP
leads to higher quality of care, improved patient outcomes, and decreased healthcare
costs (Melnyk, Fineout-Overholt, Gallagher, & Kaplan, 2012). The QSEN competency

TABLE 2.5 EVIDENCE-BASED PRACTICE LEARNING ACTIVITIES

CURRICULUM LEVEL LEARNING ACTIVITIES

Beginning level There is a body of research around barriers to
utilizing EBP in nursing practice. Read the article
titled “Evidence-Based Practice Barriers and
Facilitators From a Continuous Quality Improvement
Perspective: An Integrative Review,” by Solomons
and Spross (2011).

Does the article resonate with what you are seeing
in practice regarding the barriers for utilization of
EBP? What did the authors identify as the barriers
for continuous quality improvement in the clinical
setting?

Intermediate level Go to QSEN.org. On the search bar click the education
tab. Both faculty and students will find competencies
and teaching strategies related to evidence-
based practice. Choose one to explore. Under the
evidence-based practice tab there is a selection of
articles for both students and faculty to read.

Advanced level Nurses still struggle to get evidence into practice.
The article, “Barriers and Facilitators to the Use of
Evidence-Based Practice,” by Scott and McSherry
(2009) explains that, for evidence-based nursing to
occur, nurses need to be aware of what evidence-
based nursing means and what the process of
EBP is to apply the evidence. This article examines
the concept of evidence-based nursing and its
application to clinical practice. Use the article as a
basis for your discussion of nursing’s struggle to get
evidence into practice (Scott & McSherry, 2009).

EBP, evidence-based practice.

50 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

of evidence-based practice integrates the best current evidence with clinical expertise
and patient/family preferences and values for the delivery of optimal patient care.
Examples of this competency include the following:

• K—Describe EBP to include components of research evidence, clinical expertise,
and patient/family values.

• S—Base individualized care plans on patient values, clinical expertise, and
evidence.

• A—Value the concept of EBP as integral to determining best clinical practice
(Cronenwett et al., 2007).

Traditional medical–surgical nursing skills are now often taught along with their
bases in EBP. For example, nursing research highlights emerging best clinical practices
related to fluid balance, peripheral intravenous insertion and maintenance, urinary
catheter care, care of central lines, and nasogastric tube insertion. As confirmation of
the core role of EBP in developing clinical practice, most nursing texts now include
evidence-based support to explain rationales for clinical practice. Table 2.5 offers learn-
ing activities for this competency.

Quality Improvement

The QSEN competency of quality improvement (QI) is defined as the use of data to
monitor the outcomes of care processes and using improvement methods to design
and use changes to continuously improve the quality and safety of healthcare systems.
Nursing programs have integrated QI methods and tools to help students engage in
frontline improvement (IOM, 2003). Examples of KSAs for this competency include
the following:

• K—Recognize that nursing and other health professions students are parts of sys-
tems of care and care processes that affect outcomes for patients and families.

• S—Use tools (such as control charts and run charts) that are helpful for under-
standing variation.

• A—Appreciate that continuous QI is an essential part of the daily work of all
health professionals (Cronenwett et al., 2007).

Formal, systems-focused QI processes that engage a healthcare team, such as
adverse events reporting, should be part of the early components of the nursing
curriculum. Root cause analyses and resulting system changes are relevant to study
in a clinical nursing course. As students progress through clinical courses, they
will see many examples of nurses contributing to QI processes in the acute care
setting. Nurses are well positioned to offer insights into how to improve patient-
care processes to improve patient outcomes. Table 2.6 offers learning activities at
the beginning, intermediate, and advanced levels of nursing education for this
competency.

In addition to learning about QI from a nursing perspective, engaging with other
health professional students is an effective learning strategy. Students can learn about
QI together in classroom, simulation, and clinical settings (Headrick et al., 2012). In
fact, the IHI has established an “open school” to distribute free online courses, provide
experiential learning opportunities, as well as build community (available at www.ihi
.org/offerings/ihiopenschool).

2 QUALITY AND SAFETY EDUCATION FOR NURSES • 51

EVIDENCE FROM THE LITERATURE

Citation

Hermann, C., Head, B., Black, K., & Singleton, K. (2016, January–February). Preparing
nursing students for interprofessional practice: The interdisciplinary curriculum for
oncology palliative care education. Journal of Professional Nursing, 32(1), 60–71.

Discussion

The Interprofessional Education Collaborative, a collaboration of key educational
associations, including the American Association of Colleges of Nursing (AACN),
established core competencies for interprofessional collaborative practice that apply
to all students of the health professions. Evidence supports the collaboration of
health professionals to improve patient outcomes, especially those related to quality
and safety. This study identifies the development of an interprofessional Curriculum
for Oncology Palliative Care Education (iCOPE) using team-based palliative oncol-
ogy education as a framework for teaching students interprofessional practice skills.

Implications for Practice

The study concludes that health education can no longer be taught in separate silos,
but must take an interprofessional approach to curriculum design. Nurse educators are
ideally suited to lead these initiatives. The project serves as a model for ongoing efforts
to develop and implement interprofessional education initiatives going forward.

TABLE 2.6 QUALITY IMPROVEMENT LEARNING ACTIVITIES

CURRICULUM
LEVEL LEARNING ACTIVITIES

Beginning
level

Nurses are involved in QI work at every level of healthcare. A checklist,
developed by Peter Pronovost, around central line insertion has
standardized the practice of central line insertion and reduced central
line-associated bloodstream infections. Read Atul Gawande’s article on the
development of this checklist, paying attention to the role of nurses in the
checklist’s implementation (Gawande, 2007)

Intermediate
level

The article “Adverse Event Reporting and Quality Improvement in the
Intensive Care Unit,” by Heavner and Siner (2015) illustrates the
process of QI and adverse event reporting. Form student teams to
review an adverse event and propose system solutions.

Advanced
level

Partner with someone who works in the QI department of your hospital.
Shadow that person for 2 full days. Notice the focus of their work. Which
patient outcomes is this department tracking? How are data gathered
for these patient outcomes? What elements of nursing care are tracked
for these patient outcomes? What insight can nurses provide about the
patient-care processes to achieve these patient outcomes?

QI, quality improvement.

52 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

Safety

The safety QSEN competency minimizes risk of harm to patients and providers
through both system effectiveness and individual performance. Examples of KSAs for
this competency include the following:

• K—Examine human factors and other basic safety design principles as well as com-
monly used unsafe practices, such as work-arounds and dangerous abbreviations.

• S—Demonstrate effective use of strategies to reduce the risk of harm to self or
others.

• A—Value the contributions of standardization/reliability to safety (Cronenwett
et al., 2007).

QSEN’s definition of safety emphasizes team strategies to promote safe care in a
healthcare system rather than focusing on blaming individuals for safety issues. For
example, maintaining asepsis is a component of an individual nurse’s practice and
has multiple associated safety skills. Maintaining asepsis and reducing infections in

REAL-WORLD INTERVIEW

Quality and safety improvement is more than just a supplemental activity
complementing core clinical education in the health professions. It directly
impacts the health and lives of the people that healthcare professionals have
pledged to help and directly affects the outcomes that we need to achieve
in healthcare. Quality and safety, therefore, must be a personal commitment
and part of the core professional role identity of every healthcare profes-
sional. To achieve this, health professions education must strive to integrate
quality and safety into the core curriculum and prepare “clinician-leader-
improvers” who are ready to lead and continuously improve the work they
are doing in healthcare. QSEN is a key voice for quality and safety educa-
tion in the nursing profession. QSEN also provides guidance and resources,
which are essential in developing competence in quality and safety for
health professions. It is critical that all health professions education pro-
grams integrate the QSEN competencies into their curricula and engage stu-
dents in meaningful applied quality and safety education experiences at the
beginning of their educational development and then onward into profes-
sional practice. To a great degree, the future of our health is in the hands of
our students and in their efforts to improve healthcare quality and safety. As
such, health profession educators have a critical obligation to help them to
develop not only as clinicians, but as leaders and improvers

Brant J. Oliver, PhD, MS, MPH, APRN-BC
Assistant Professor, The Dartmouth Institute &

Geisel School of Medicine at Dartmouth
Adjunct Associate Professor, School of Nursing

MGH Institute of Health Professions
Faculty Senior Scholar

Veteran’s Affairs National Quality Fellowship
in Healthcare Quality and Safety

REAL-WORLD INTERVIEW

2 QUALITY AND SAFETY EDUCATION FOR NURSES • 53

one’s practice also has direct implications for supporting patient outcomes related to
various national safety goals in a healthcare system. The National Patient Safety Goals
(The Joint Commission, 2012), 5 Million Lives Campaign (IHI, 2012), and Safe Practices
for Better Healthcare (National Quality Forum, 2009) all state common goals around
decreasing nosocomial infection rates in the acute care setting. Table 2.7 offers learning
activities at the beginning, intermediate, and advanced level of nursing education for
the competency.

At the heart of our social identity as professionals is the ability to continually
learn and improve our own work. No longer soloists, most of today’s healthcare
work is done with others. Interdependently, patients, families and people from
multiple health professional disciplines work in complex, complicated and
simple systems to cocreate and coproduce healthcare services. Changing and
improving the coproductive work of relationships and actions requires diverse
knowledge and skills (Batalden et al., 2016).

The European safety scholars, Charles Vincent and Rene Amalberti,
remind us that, “we need to see safety through the patient’s eyes, to consider
how safety is managed in different contexts and to develop a wider strategic
and practical vision in which patient safety is recast as the management of
risk over time” (Vincent & Amalberti, 2016). This will involve moving from a
focus on unusual events of failure and harm in hospital settings to a focus on
the patient’s journey over time. Attention to the coproduction and the coor-
dination of services over time in diverse settings will open a new chapter in
traditional safety efforts.

Paul Batalden, MD
Active Emeritus Professor

The Dartmouth Institute for Health Policy & Clinical Practice

Batalden, M., Batalden, P., Margolis, P., Seid, M., Armstrong, G., Opipari-
Arrigan, L., & Hartung, H. (2016). Coproduction of healthcare service. BMJ
Quality & Safety, 25, 509–517.

Vincent, C., & Amalberti, R. (2016). Safer healthcare: Strategies for the real world.
Switzerland: Springer Open.

REAL-WORLD INTERVIEW

You are a new nurse working in a busy operating room. You notice that in the
past month, three patients being transferred from the same adult patient-care
unit in the hospital have not been given their preoperative antibiotics prior to
transfer to the operating room.

1. What patient-care processes might you address to attend to this recurring issue?
2. What data might you need?
3. Who would you invite to a meeting to address this patient-care issue?

CASE STUDY 2.3

54 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

Informatics

The QSEN competency of informatics calls for the use of information and technology
to communicate, manage knowledge, mitigate (prevent) error, and support decision
making. KSAs from this competency include the following:

• K—Explain why information and technology skills are essential for safe patient
care.

• S—Apply technology and information management tools to support safe pro-
cesses of care.

• A—Value technologies supporting decision making, error prevention, and care
coordination (Cronenwett et al., 2007).

Documentation is an important skill in healthcare informatics. All members of a
healthcare team contribute to an electronic health record that is used extensively
to document shifting patient-care priorities. A broader view of informatics empha-
sizes not only documenting the patient care provided but also encourages the use
of informatics in computerized clinical alerts and decision management. For exam-
ple, a clinical alert signals to the provider that the patient is eligible to receive the
pneumonia or flu vaccine. Decision management in healthcare focuses on having
the appropriate data available at points in the decision making process to be able to
make the best decision in a timely fashion. Data used in decision management may
come from patient records, diagnostic results, providers’ documentation, or EBPs.
Table 2.8 offers learning activities at the beginning, intermediate, and advanced lev-
els of nursing education regarding this competency.

QSEN COMPETENCIES RELATED TO NURSING EDUCATION
ACCREDITATION STANDARDS

Nursing education accreditation standards are driven by rapid changes occur-
ring in nursing practice. Several national reports have focused on the need for
updated quality and safety content in nursing education. A 2010 report by the

TABLE 2.7 SAFETY LEARNING ACTIVITIES

CURRICULUM LEVEL LEARNING ACTIVITIES

Beginning level Read and discuss the National Patient Safety Goals with
colleagues. Describe how they apply in clinical practice.
Go to www.jointcommission.org/2018_national_patient_
safety_goals_presentation/ for a free 2018 National Patient
Safety Goals slide presentation.

Intermediate level The article “Lesson From Colorado: Beyond Blaming
Individuals,” by Smetzer (1998) summarizes the system
failures that led to a sentinel event with a newborn.

Advanced level Note the Nine Patient Safety Solutions identified by The Joint
Commission and the World Health Organization: The purpose
of the Nine Patient Safety Solutions is to guide the redesign
of patient-care processes to prevent inevitable human errors
from actually reaching patients. See www.who.int/mediacentre/
news/releases/2007/pr22/en

2 QUALITY AND SAFETY EDUCATION FOR NURSES • 55

Carnegie Foundation for the Advancement of Teaching titled Educating Nurses:
A Call for Radical Transformation, recommended several initiatives to address the
practice–education gap (Benner, Sutphen, Leonard, & Day, 2010). The report’s
authors emphasize that both didactic academic classroom teaching and clinical
practice teaching models need to more fully reflect the current healthcare empha-
sis on QI and patient safety. An interprofessional report published by the IOM
in 2011, The Future of Nursing: Leading Change, Advancing Health, includes the key
message that nurses need to be full partners with other healthcare team members
to redesign healthcare in the United States. Quality and safety are two significant
areas where interprofessional, collaborative efforts are needed to redesign U.S.
healthcare systems. Accreditation standards for nursing programs have begun to
clearly articulate the need for quality and safety content in prelicensure curricula.
Standards from accrediting bodies for nursing programs, that is, the Accreditation
Commission for Education in Nursing (ACEN), formerly the National League for
Nursing Accrediting Commission (NLNAC), and the AACN are explicit about the
necessity for the QSEN competencies in all nursing prelicensure curricula.

Table 2.9 connects each of the AACN Essentials of Baccalaureate Education to
QSEN competencies. Many of the AACN Essentials of Baccalaureate Education con-
tain several guidelines for prelicensure curricula, thus the connection to more than one
QSEN competency in Table 2.9.

ACEN’s accreditation standards similarly encourage the integration of QSEN
competencies into prelicensure curricula. Table 2.10 connects several of the ACEN
standards to QSEN competencies.

TABLE 2.8 INFORMATICS LEARNING ACTIVITIES

CURRICULUM
LEVEL LEARNING ACTIVITIES

Beginning level Many patients use Internet resources to become educated
about their diagnosis. Use this QSEN learning activity to
evaluate a health-related website that one of your patients
may use. There is an evaluation form provided at qsen.org/
website-evaluation-exercise.

Intermediate
level

The Commission on Systematic Interoperability has been
charged with developing a strategy to make healthcare
information increasingly accessible at various care points in
the healthcare process. Access the following website: www.
endingthedocumentgame.gov. Click on the personal stories
link and read the narratives provided by patients, healthcare
professionals, and nurses about the importance of timely
access to patient data.

Advanced level Consider the number of electronic health records (EHRs) you have
experienced during your nursing rotations. Answer the following
questions:

1. How many EHR systems have you seen in your various clinical
rotations?

2. What similarities have you seen among EHR systems?
3. Which EHR system seemed most “nurse friendly”? Identify what

you mean by “nurse friendly.”
4. What improvements do you think need to be made to existing

EHR systems in the acute care setting to better support nursing
care needs?

56 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

QSEN RESOURCES

The QSEN website (www.qsen.org) has many resources for nurses, nursing stu-
dents, and nursing faculty. Available on the website under the education tab are
the competencies and KSAs for prelicensure nurses and graduate nurses. Here,
students and faculty can read peer-reviewed articles on relevant teaching strat-
egies and EBPs related to the QSEN competencies. Under the resource tab, fac-
ulty can access 18 learning modules that will assist them in integrating quality
and safety competencies into their programs. The learning modules address top-
ics such as appreciating and managing the complexity of nursing work, cognitive
stacking (a process that assists students to more effectively manage the complexity
of their work to promote safe, quality care), informatics, and other topics relevant
for practicing nurses. Books, reports, toolkits, articles, and presentations can also
be accessed under this tab. Under the publications tab, there are books and videos
that highlight exemplar cases such as the Lewis Blackman story and the Josie King
case. Both exemplar cases are potent tools that highlight the vital importance of
quality and safety in nursing practice. Teaching strategies can be found in peer-
reviewed articles at the site.

TABLE 2.10 SELECTED ACEN STANDARDS AND QSEN COMPETENCIES

ACEN STANDARD QSEN COMPETENCY

4.5. The curriculum includes cultural, ethnic, and socially
diverse concepts and may also include experiences
from regional, national, or global perspectives.

PCC

4.6. The curriculum and instructional processes reflect
educational theory, interprofessional collaboration,
research, and current standards of practice.

Teamwork and collaboration
Evidence-based practice
QI

4.10. Students participate in clinical experiences
that are evidence-based and reflect contemporary
practice and nationally established patient health
and safety goals.

Safety
QI

ACEN, Accreditation Commission for Education in Nursing; PCC, patient-centered care; QI, quality improvement.

Source: Developed with information from the ACEN (2013).

TABLE 2.9 SELECTED ACEN ESSENTIALS OF BACCALAUREATE EDUCATION AND QSEN
COMPETENCIES

AACN ESSENTIALS OF BACCALAUREATE EDUCATION QSEN COMPETENCY

II: Basic Organizational and Systems Leadership for
Quality Care and Patient Safety

QI
Safety

III: Scholarship for Evidence-Based Practice Evidence-based practice
IV: Information Management and Application of Patient

Care Technology
Informatics

V: Interprofessional Communication and Collaboration
for Improving Patient Health Outcomes

Teamwork and collaboration
QI

AACN, American Association of Colleges of Nursing.

Source: Developed with information from the American Association of Colleges of Nursing (AACN). (2008). The
essentials of baccalaureate education for professional nursing practice. Retrieved from http://www.aacnnursing.org/
Portals/42/Publications/BaccEssentials08.pdf

2 QUALITY AND SAFETY EDUCATION FOR NURSES • 57

All of the relevant professional organizations that are making great strides
in improving quality and safety in healthcare (e.g., IHI, www.ihi.org; Agency for
Healthcare Research and Quality Patient Safety Network, psnet.ahrq.gov; National
Association for Healthcare Quality, nahq.org/ and the NPSF, www.npsf.org) as well as
many others can be found on the QSEN website. QSEN’s well-designed website is an
invaluable, updated resource for all nurses and nurse educators.

SPECIAL ISSUES OF NURSING JOURNALS THAT HAVE
FOCUSED ON QSEN

Nurse Educator (2017) published a QSEN-dedicated issue in the September/October
edition and included articles focused on QSEN’S impact on curriculum develop-
ment in schools of nursing to date, as well as advancements in the integration of the
QSEN competencies in the clinical setting. Earlier work in both Nursing Outlook (2009),
November/December, 57 (6), and Journal of Nursing Education (2009), December, 48
(12) published QSEN-dedicated issues that are valuable resources and provide a sub-
stantive contribution to the literature about the importance and logistics of implement-
ing QSEN competencies in nursing curricula.

CRITICAL THINKING 2.2

Go to this link at the IHI website: www.ihi.org/knowledge/Pages/HowtoImprove/
ScienceofImprovementHowtoImprove.aspx

Read about the Model for Improvement. Consider a unit-based project on an adult
patient-care unit where a nurse wants to address decreasing the decubitus ulcer rate
on her unit. Using the Model for Improvement with its three fundamental questions
and its Plan-Do-Study-Act (PDSA) cycle as a model for such a project, answer the
following questions:

1. What team members would have important input on this team?
2. Imagine yourself on the QI team. What change are you trying to accomplish?
3. What might be your goal?
4. What data will you collect that will show that your changes made a

difference?

KEY CONCEPTS

• Historically, a major push for the six competencies of the QSEN initiative came from
the 2003 IOM report, Health Professions Education: A Bridge to Quality, where competen-
cies in quality and safety were recommended for all health professions students.

• All six of the QSEN competencies, that is, PCC, QI, safety, teamwork and collabora-
tion, EBP, and informatics, are integral aspects of nursing clinical practice.

58 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

• Each of the six QSEN competencies has KSA elements that help operationalize each
competency for practice.

• The QSEN competencies are fundamental components of accreditation standards for
nursing programs and are integrated into beginning, intermediate, and advanced
level nursing courses.

• There are a wide variety of quality and safety resources available for nurses at the
QSEN website (www.qsen.org).

• There are several special issues of nursing journals that have focused on QSEN.

KEY TERMS

Attitudes
Evidence-based practice
Informatics
Knowledge
Patient-centered care
Quality improvement

Rapid response teams
Safety
Safety science
Skills
Teamwork and collaboration

REVIEW QUESTIONS

1. The nurse is caring for a newly admitted patient. She introduces herself using her
first and last names and asks the patient what his values, needs, and preferences
are for this hospital stay. The nurse is practicing which of the QSEN competencies?

A. Evidence-based practice
B. Safety
C. Patient-centered care
D. Teamwork and collaboration

2. The primary nurse is caring for a patient admitted to the unit from a nursing home
with a Stage III decubitus ulcer. In looking at the electronic nursing notes, she
notes a discrepancy in the patient’s wound care procedures. The primary nurse
calls the wound care nurse to consult and ensure a consistent plan of care. The
wound care nurse assesses the patient and provides the necessary information
reflecting the standard of care. The primary nurse is practicing which of the QSEN
competencies? Select all that apply.

A. QI
B. Safety
C. Teamwork and collaboration
D. PCC
E. Informatics

3. The nurse is transferring his patient to the Post Anesthesia Care Unit (PACU) from
the surgical unit. He is calling the receiving nurse with a patient handoff report.
Ensuring patient safety by using the handoff report, he is careful to describe the
situation, background, assessment, and recommendation for the patient’s con-
tinued care. Giving an accurate handoff report is an example of ensuring patient
safety by using which QSEN competency?

A. Teamwork and collaboration
B. QI

2 QUALITY AND SAFETY EDUCATION FOR NURSES • 59

C. PCC
D. Informatics

4. The nurse notices that there was an earlier medication error that resulted in an
adverse patient outcome. She asks for assistance from her manager in analyzing
the error. This is an example of using which QSEN competency?

A. Safety
B. QI
C. PCC
D. Teamwork and collaboration

5. A medical resident walks into a patient’s room to complete a physical assess-
ment. The nurse notices that the resident did not wash her hands before entering
the room. The nurse gently reminds the resident to use the hand sanitizer before
touching the patient. This reminder is an example of using which of the following
QSEN competencies?

A. Safety
B. QI
C. PCC
D. Teamwork and collaboration
E. Informatics

6. The nurse is using barcode administration technology to facilitate the administra-
tion of medications to her patients. This is an example of how barcode medication
administration technology facilitates which of the following QSEN competencies?

A. Teamwork and collaboration
B. Safety
C. Informatics
D. EBP
E. QI

7. The nurse is participating in a team meeting with her patient, the dietician, phy-
sician, and social worker. The nurse recalls that the patient had expressed that
spirituality was important to her. A pastoral care representative is not present in
the meeting. The nurse notices this and contacts pastoral care to be included in the
meeting. This inclusion is an example of using which QSEN competency?

A. Teamwork and collaboration
B. Safety
C. PCC
D. Informatics

8. The nurse realizes that her patient’s pain management is not effective. She has
noticed this with other patients in the past and decides to analyze the unit-based
pain control chart posted in the break room. She decides to explore additional pain
management options for patients whose pain is not controlled with the usual pain
management. Which QSEN competencies best describes her approach?

A. Safety
B. QI
C. PCC
D. Teamwork and collaboration

60 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

9. In administering medication to her patient, the nurse saw that the medication
administration record indicated the dose amount to be 5 mg. She immediately
double checked the order and confirmed that the dose was supposed to be 0.5 mg.
The nurse remembered to always use a zero before a decimal when the dose is less
than a whole unit and she updated the medication administration record accord-
ingly. Which QSEN competency applies?

A. Safety
B. QI
C. PCC
D. Teamwork and collaboration

10. The nurse is concerned about his patient’s lab values and medication regimen.
The nurse uses the electronic health record to obtain information about medica-
tion doses, lab results, and notes that the patient’s lab results are within normal
limits. This use of the electronic health record is an example of using which QSEN
competency?

A. Teamwork and collaboration
B. Safety
C. PCC
D. Informatics

REVIEW ACTIVITIES

1. Select one of the six QSEN competencies from the QSEN website (www.qsen.org)
and create a 60-second video explaining the competency that was chosen and why
it matters to professional nursing practice. Present the video in class and lead a
discussion on the video’s application to practice.

2. Interview three nurses on the unit where you are currently doing a clinical rota-
tion. Ask each nurse, “What is the most pressing patient safety issue on this unit?”
Take notes. Compare the nurses’ answers. Discuss the results with your classmates
and instructor in post conference. What did you find?

CRITICAL DISCUSSION POINTS

1. Discuss the importance of what QSEN has accomplished to date.
• Defined quality and safety competencies for nursing and proposed targets for the

KSAs to be developed in nursing prelicensure programs for each competency:
patient-centered care, teamwork and collaboration, EBP, QI, safety, and informatics.

• Completed a national survey of baccalaureate nursing program leaders and a
state survey of associate degree nursing educators to assess beliefs about the
extent to which the competencies are included in current curricula, the level
of satisfaction with student competency achievement, and the level of faculty
expertise in teaching the competencies.

• Partnered with representatives of organizations that represent advanced prac-
tice nurses and drafted proposed KSA targets for graduate education.

• Funded work with 15 pilot schools committed to active engagement in curricu-
lar change to incorporate quality and safety competencies

• Discussed the goals of the QSEN competencies at the prelicensure level.

2 QUALITY AND SAFETY EDUCATION FOR NURSES • 61

• Set the overall goal for QSEN to meet the challenge of preparing future nurses
who will have the KSAs necessary to continuously improve the quality and
safety of the healthcare systems in which they work.

2. Discuss one potential barrier for incorporating the QSEN competencies in a
patient’s plan of care. Are any of the following an issue in your clinical setting?
• Lack of teamwork and collaboration among the interprofessional team members.
• Developing a plan of care without consideration of the preferences/values of

the patient/family.
• Poor handoffs when a patient is being transferred from one unit to another.

3. Using the QSEN competency of teamwork and collaboration, discuss how you would
apply those KSAs to a complex clinical situation.

4. Why it is essential that the QSEN competencies align with accreditation standards?
5. Select one article from The Journal of Nursing Education, September/October 2017,

QSEN Supplement, and reflect on how the article is related to your practice.
Discuss with colleagues what you have learned.

6. Discuss in class some of the most useful resources on the QSEN website.
• Competencies
• Teaching strategies
• QSEN integration modules
• Learning modules
• Books, reports, toolkits
• Evaluation tools
• Videos
• Conferences

7. What does the word “systems thinking” mean to you related to the QSEN
competencies?

QSEN ACTIVITIES

1. Explore the teaching strategies published on the QSEN Website (www.qsen.org).
These are peer-reviewed teaching strategies published on the site. Ask students to
choose one of the strategies and apply it to a clinical situation. Discuss an imple-
mentation plan for the strategy chosen. Discuss which QSEN competencies apply.

2. Select one of the six QSEN competencies from the QSEN website (www.qsen.org)
and create a 60-second video explaining the competency they chose and why it
matters to professional nursing practice. Have students present the video in class
and lead a discussion on the video’s application to practice.

EXPLORING THE WEB

1. National Patient Safety Foundation—www.npsf.org
2. QSEN Institute—www.qsen.org
3. Institute for Healthcare Improvement—www.ihi.org
4. TeamSTEPPS—www.teamstepps.ahrq.gov
5. IHI Open School—www.ihi.org/offerings/ihiopenschool
6. Agency for Healthcare Research and Quality Patient Safety Network—psnet.ahrq

.gov
7. National Association for Healthcare Quality. Q Essentials Info Session February

2016—www.youtube.com/watch?v=kP9-8V93s30

62 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

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Hermann, C., Head, B., Black, K., & Singleton, K. (2016, January–February). Preparing nursing
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education-a-bridge-to-quality

Institute of Medicine (IOM). (2010). Assessing progress on the institute of medicine report the future
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nursing

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Institute of Medicine (IOM). (2011). The future of nursing: Leading change, advancing health.
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SUGGESTED READING

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Clinical nursing education: Current reflections (pp. 207–227). Washington, DC: National
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Altmiller, G., & Dolansky, M. A. (2017, September/October). Quality and safety education for
nurses: Looking forward. Nurse Educator, QSEN Supplement, 42(5), S1–S2.

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safety and quality in pediatric pain management. Pediatrics, 131, e921–e927. doi:10.1542/
peds.2012-1378

Cohen, N. L. (2013). Using the ABCs of situational awareness for patient safety. Nursing, 43,
64–65. doi:10.1097/01.NURSE.0000428332.23978.82

64 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

Dekker, S. (2011). Patient safety: A human factors approach. Boca Raton, FL: CRC Press.
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St. Martin’s Press.
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learning of nursing quality and safety competencies. Nurse Educator, 38, 71–75. doi:10.1097/
NNE.0b013e3182829c7d

Triola, N. (2006). Dialogue and discourse: Are we having the right conversation. Critical Care
Nurse, 26, 60–66. AACN

Wachter, R. M. (2008). Understanding patient safety. New York, NY: McGraw-Hill.

Upon completion of this chapter, the reader should be able to

1. Explain major leadership theories in relation to the Quality and Safety
Education for Nurses (QSEN).

2. Describe roles and responsibilities of leadership.

3. Define management as distinguished from leadership.

4. Discuss the importance of followership in relation to an organization’s
mission and vision.

5. Explain how the hospital’s finances influence safety and quality of patient
care.

6. Describe how a budget influences staffing.

7. Discuss the importance of the Code of Ethics for Nurses.

8. Discuss the importance of Emancipatory Knowing in relation to the call for
every nurse to function as a leader.

9. Discuss the four key elements of the Future of Nursing (FON): Campaign for
Action in the context of functioning as a leader at all levels of care.

NURSES AS LEADERS AND MANAGERS
FOR SAFE, HIGH-QUALITY PATIENT CARE

Carolyn A. Christie-McAuliffe

All truth passes through three stages: first it is ridiculed; second it is violently opposed; third it is accepted
as being self-evident.

—Arthur Schopenhauer

3

66 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

S
ally graduated from nursing school a year ago and is now working full time on a medical–
surgical floor. Several novice nurses with no prior nursing experience have joined the
staff and expressed feeling overwhelmed with all there is to know and be done. Sally
is happy to have the additional help; however, she has noticed many patients are not

being assisted out of bed or ambulated. She clearly remembers her first few months out of school
and empathizes with the new nurses’ feelings. However, she is also worried about the risk of
pneumonia, bedsores, and other health complications in patients who remain in bed for extended
periods of time.

• What can Sally do to support her new colleagues?
• What are some things Sally can do to support her colleagues’ patients?
• What could Sally do to prevent a similar situation the next time the floor hires new graduates?

Leadership is frequently described in terms of personal attributes such as having
confidence and being strong. Often, these leadership attributes have been assumed to
be a quality one has been born with or cultivated by how the person has been raised.
However, many experts now argue leadership can be taught, fostered, and refined.
Many nurse leaders agree with this more contemporary viewpoint. Specifically, they
are calling for nursing education that incorporates leadership content which encour-
ages nurses to demonstrate leadership at all levels of nursing practice. The leader-
ship they advocate would directly and indirectly impact the safety and quality of
patient care.

This chapter provides the foundation for understanding leadership and this new
call to action. Theories are presented as context for discussion as leadership is dis-
cussed in relation to management and followership. Similarities and differences of
the qualities, roles, and responsibilities of leadership, managers, and followers are
described within the framework of economic and financial constraints. The impact of
economics and finance will be discussed in relation to the ability to deliver safe, qual-
ity care. However, the emphasis of this chapter is substantiating the need to shift the
focus of care from individual patients to now include care of the healthcare system
as well. This substantiation comes from many influences, including Nursing’s Social
Contract as well as the Code of Ethics for Nurses, the Quality and Safety Education
for Nurses (QSEN), the Future of Nursing (FON) Campaign for Action, and the under-
standing of Emancipatory Knowing.

Nursing has a rich history of leading change. Florence Nightingale, Clara Barton,
Margaret Sanger, and Hazel Johnson-Brown are but a few nurses who have advanced
nursing and healthcare through their efforts to facilitate change. More recently, lead-
ership has been demonstrated by nursing in response to the Institute of Medicine’s
(IOM) reports, To Err Is Human: Building a Safer Health System (2000) and Crossing the
Quality Chasm (2001), which documented the need to restructure the healthcare sys-
tem. These reports revealed issues of both safety and quality of care, specifically in
the context of increased complexity within the healthcare system. The IOM reports
identified many causes of this complexity, including the health status of patients,
technology, as well as economics, politics, and social factors. National organizations
such as The Joint Commission (TJC) and the Institute for Healthcare Improvement
(IHI) launched programs in response to the IOM findings. Similarly, nurse leaders
responded to the same IOM findings at local, state, and national levels with many
initiatives; however, two of these initiatives stand out: The QSEN Initiative and the
FON: Campaign for Action.

In 2005, QSEN was formed to develop competencies of knowledge, attitude, and
skill related to safety of patient care and as a means to ensure continuous quality

3 NURSES AS LEADERS AND MANAGERS FOR SAFE, HIGH-QUALITY PATIENT CARE • 67

improvement in healthcare organizations and institutions. Six core competencies
were developed with measures differentiated at prelicensure and graduate levels
as follows:

1. Patient-Centered Care
2. Teamwork and Collaboration
3. Evidence-Based Practice (EBP)
4. Quality Improvement (QI)
5. Safety
6. Informatics (QSEN, 2017)

The aim of the QSEN competencies was and is to provide relevant materials and
resources to nurse educators that can be incorporated into existing curricula.
In addition, QSEN wanted to provide objective measures of knowledge, attitude, and
skill that nurse faculty could use to determine if students understood and could apply
interventions aimed at increasing safety and quality of care. Since its formation, QSEN
has funded and/or supported innovative programs in specific schools, the Veterans
Administration, the American Association of Colleges of Nursing, and more.

The FON: Campaign for Action is another powerful initiative within nursing.
In 2008, the Robert Wood Johnson Foundation (RWJF) partnered with the IOM to
launch a specific study investigating the role of nursing in transforming health-
care. Their research discovered much diversity of educational preparation, unde-
rutilization of nursing knowledge and skill, and fragmentation of purpose within
the nursing profession. However, they also found great potential. In 2011, the IOM
published The Future of Nursing: Leading Change, Advancing Health. In this report,
eight recommendations were offered to policymakers, educators, healthcare organi-
zations, and businesses, as follows:

1. Remove scope-of-practice barriers.
2. Expand opportunities for nurses to lead and diffuse collaborative improvement

efforts.
3. Implement nurse residency programs.
4. Increase the proportion of nurses with a baccalaureate degree to 80% by 2020.
5. Double the number of nurses with a doctorate by 2020.
6. Ensure that nurses engage in lifelong learning.
7. Prepare and enable nurses to lead change to advance health.
8. Build an infrastructure for the collection and analysis of interprofessional health-

care workforce data (IOM, 2011, pp. 9–15).

As a result of this report, the RWJF joined forces with AARP (formerly known as the
American Association of Retired Persons) to create the FON: Campaign for Action. All
50 states now have an Action Coalition Committee aimed at meeting the eight recom-
mendations of the IOM report.

Despite these initiatives, little improvement in safety and quality of care has been
demonstrated. The call to action has never been more ardent or urgent. Nurses at all
levels, from the patient bedside to the boardroom, are now asked to step into their
authentic power with moral courage to be leaders for change. No longer can responsi-
bility for leading change sit solely with nurse administrators or academicians; nurses at
every level of educational preparation and position are now called to improve patient
safety and quality of care within the healthcare system in which they work, as well as
with individual patients. As a profession, nursing now realizes all nurses should func-
tion as leaders to heal patients as well as the healthcare system.

68 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

Cultivating leadership in nursing has not been stud-
ied extensively. However, residency programs for new
graduate nurses have provided some valuable insight.
Curtis, de Vries, and Sheerin (2011) discuss factors that
contribute to leadership in nursing including the offer-
ing of educational activities and role modeling as well
as the opportunity to practice leadership skills. They dis-
cuss being open to new ideas and being extroverted as
traits likely to foster leadership. Likewise, the role of age
and experiences are positive influences. Interestingly,
they found the most important skill necessary for lead-
ership involved fostering effective relationships. They
describe this specific skill as more important than
knowledge surrounding management skill or technical
abilities (Figure 3.1). They found that the most impor-
tant qualities of effective relationships include effective
communication, approachability, and emotional intelli-
gence. Wagner, Cummings, Smith, Olson, Anderson, and
Warren (2010), as cited in Curtis et al. (2011), discovered
the organizations that promoted nurse empowerment
resulted in increased “positive work behaviors and atti-
tudes, including leadership behavior” (p. 308).

LEADERSHIP THEORY

Historical review of how leadership has been perceived provides insight into how and
why nursing gravitates to some leadership theories over others. During the Industrial
Revolution, leadership was focused almost exclusively on how to manage productiv-
ity. Success was measured by precise, scientific measurements and standards, which
was appropriate and beneficial for institutions primarily focused on manufacturing.
During the mid-20th century, organizations identified the need for clearer structure
and standardization. Max Weber (1864–1920) offered a theoretical framework based
on establishing a hierarchy of authority and power that clearly delineated policies
and procedures as a way of standardizing work. As institutions grew focused mainly
on efficiency and growth, a dehumanizing quality to administration and leadership
developed. In response, government organizations enacted regulations to protect
workers. With this national shift, unions formed to further ensure safe and fair work-
ing conditions. The focus of leadership then evolved further to the individual within
an organization, specifically looking at maximizing their efforts and strengths. With
this new focus, a movement toward “human relations” emerged that continues today.
Many, if not most, contemporary leadership theories are based on the behavioral sci-
ences, which aim to explain human behavior. This perspective of leadership provides
organizations with a better understanding of what influences behavior. Having a clear
understanding of what an organization wants allows its leaders improved ability to
manage those influences.

Dinh et al. (2014) conducted a comprehensive literature review of established
and emerging leadership theories that revealed 23 thematic categories and 66
domains or areas of foci. Nursing does not espouse a single theory of leadership
but, rather, most often views leadership through the lens of nursing theory, incor-
porating and applying relevant leadership theory as appropriate. Three commonly

FIGURE 3.1 Leadership as
mentor.

3 NURSES AS LEADERS AND MANAGERS FOR SAFE, HIGH-QUALITY PATIENT CARE • 69

referred to theories of leadership that nursing utilizes include Chaos, Quantum,
and Systems Theories. Each of these theories relates and interrelates to each other.

Chaos Theory

Chaos theory is based on the belief that underneath the seemingly unpredictable
nature of life and/or business, a pattern or order exists. While many leadership styles
and strategies are based on the belief that events are predictable and can be controlled,
Chaos Theory calls for leaders to be vigilant to the dynamic changing nature of eco-
nomic, political, and social cues. This awareness allows leaders to guide their orga-
nization through disorder. By seeking insight from these cues, the leader finds a new
pattern of understanding. Through this pattern of understanding, leaders accept the
reality of complexity as well as unpredictability in order to learn to anticipate needed
change and flexibility (Porter-O’Grady & Malloch, 2011). The leader then translates
this understanding for the need for change and flexibility to the organization in a way
that provides relevance, importance, and direction.

Quantum Theory

Quantum Theory acknowledges the complexity and chaotic nature of life. This theory
is based on quantum physics, which states particles or matter can exist simultaneously
in two different states of being. Quantum Theory asks leaders to simultaneously con-
sider the reality of a situation and the potential or ideal. Porter-O’Grady and Malloch
(2011) explain that in order to achieve this requirement, leaders must adopt a whole
systems approach versus an approach of individual parts. They explain that every
part of a system is part of one comprehensive system and smaller systems are linked
to form larger, more complex systems. This explanation provides the need and benefit
of interdependence (Box 3.1). They continue their explanation that Quantum Theory
requires leaders to focus on outcomes, not the process; in other words, what a job or

In nature, everything is interdependent. There is an ebb and flow among all elements of
life. Leaders must see their role from this perspective. Most of the work of leadership will
be managing the interactions and connections between people and processes. Leaders
must keep aware of the following truths:
• Action in one place has an effect in other places.
• Fluctuation of mutuality means authority moves between people (followers can be

leaders and leaders can be followers in a dynamic relationship).
• Interacting properties in systems make outcomes mobile and fluid (function in the

present but work toward the future).
• Relationship building is the primary work of leadership.
• Trusting feeling is as important as valuing thinking.
• Acknowledging in others what is unique in their contribution is vital.
• Supporting, stretching, challenging, pushing, and helping are part of being present to

the process, to the players, and to the outcome (Porter-O’Grady & Malloch, 2011, p. 22).

BOX 3.1 INTERDEPENDENCE

70 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

work results in rather than just that someone preformed the work for work’s sake. It
asks leaders to emerge from all levels of nursing, independent of educational prepara-
tion or position, learning to adapt to dynamic, unpredictable change in order to see
what is alongside what could be. In this way, the leader functions for the present but
works toward the future.

Systems Theory

Systems Theory espouses the same belief as Quantum Theory that all parts of a system are
vital and interdependent of the whole. Based on General Systems Theory developed by
biologist von Bertalanffy, Systems Theory addresses seven fundamental elements: input
(resources), output (product or service), throughput (planning), feedback (data on ser-
vice or product that allow for self-correction), control (evaluation), environment (milieu),
and goals (vision, mission). Ultimately, to be viable or sustainable, an organization as a
system, must have a clear vision and mission that is substantiated by feedback and able
to adapt to changing economic, political, and social conditions. Dolansky and Moore
(2013) argue Systems Theory or thinking allows nurses to move from a specific focus on
individual patient care to a perspective that sees patient care in the context of the care
of the “system.” In this broadened and more global view, the nurse is able to appreciate
and impact safety and quality of care on multiple levels. With this viewpoint, nurses are
able to see how various actions benefit the patient directly and indirectly. Their example
(Figure 3.2) of how this occurs on a continuum is poignantly illustrative.

Leadership Defined

Leadership can be explained or described in many ways; however, simply put, leader-
ship is the ability to lead or command a person or group of people (Figure 3.3). In this
simplistic perspective, anyone who leads and facilitates change by speaking up, pro-
viding education, role modeling, and/or coaching resulting in changed behavior of an
individual or group is a leader. As mentioned earlier, historically, leadership has been
viewed as something a person is born with that demonstrates a list of specific charac-
teristics. That viewpoint is no longer considered accurate. More contemporary views of
leadership consider the possibility of success to be a cocreation of a group that allows
for creativity and innovation. Grossman and Valiga (2016) explain this cocreation and
shared responsibility for success occurs when a group can appreciate and foster one
another’s strengths and attributes and commit to inspiring each other, as well as to be
self-aware, insightful, and accountable. The qualities of responsibility and accountabil-
ity share a sense of fidelity or dependability to others. Both of these qualities are com-
ponents of being a leader; however, each quality is slightly different from the another.

Personal Effort/
Individual Care

Systems Thinking/
System Care

I will turn my
patient

I will post a note
above the bed to
remind others

I will ask other nurses
about products to
prevent ulcers

I will compare our
unit ulcer rate with
benchmarks

FIGURE 3.2 Example of continuum of systems thinking for quality
and safety in healthcare.
Source: From Dolansky, M. A., & Moore, S. M. (2013). Quality and safety education for nurses
(QSEN): The key is systems thinking. The Online Journal of Issues in Nursing, 18(3), Manuscript 1.
Retrieved from https://www.nursingworld.org/Quality-and-Safety-Education-for-Nurses.html

3 NURSES AS LEADERS AND MANAGERS FOR SAFE, HIGH-QUALITY PATIENT CARE • 71

Responsibility is typically a requirement
of assigned tasks, roles, and/or a position
(i.e., a staff nurse on a medical surgical
floor is responsible for monitoring vital
signs of her assigned patients), whereas
accountability speaks to one’s willingness
to accept responsibility for an assignment
(i.e., the nurse accepts accountability for
all assignments related to her job).

Nursing leaders such as Porter-
O’Grady and Malloch (2011) distinguish
leadership that simply facilitates change
from that which transforms, explaining,
“A transformational leader creates a new
and improved system that allows individ-
uals to contribute to their fullest potential
to deliver the most effective healthcare possible” (p. 375). As described earlier, this
model of leadership abdicates sole “control” by the individual or individuals holding
formal, authorized power in exchange for shared ownership. In this new model, every-
one involved owns responsibility to identify strengths, weaknesses, and opportunities.

ROLES AND RESPONSIBILITIES OF LEADERS

Distinct roles and responsibilities are associated with the various positions within an
organization. These are typically outlined in a job description. A role is a position or
the part the position fulfills within an organization, such as a CEO or Vice President
(VP) of Nursing. Depending on the formal position, appropriate responsibilities will
be delegated or assigned. For a leader, these roles typically involve developing a vision
and facilitating change on a large scale, such as for a department or institution. John
Gardner (1993), considered one of the experts in the field of leadership, distinguishes
leaders from managers in six respects. Leaders:

1. Think long term.
2. Influence the organization/unit they lead.
3. Reach out to those impacted by, as well as those impacting their organization.
4. Focus on facilitating a vision by actualizing values through motivation and guidance.
5. Exhibit political skill in managing conflict related to multiple and potentially differ-

ing and/or competing priorities.
6. Include measures to always improve how an organization or institution functions

to meet their stated mission and vision.

Gardner (1993) further distinguishes the tasks or responsibility of the leader to include,
first and foremost, that of creating a vision for the group. This vision includes a detailed
plan as well as directions for managing conflict that might arise from competing goals.
The second task of the leader involves affirming the organization or group’s values,
vision, and mission, which might include facilitating agreement between people or
groups with opposing thoughts. The third task of the leader is to motivate the group
by fostering ownership, positivity, and excitement for what has been committed to by
the group. Managing priorities and work in order to actualize the group’s vision and
mission is the fourth task of the leader, whereas the fifth task is to facilitate cohesion
of mind and purpose. This fifth task is accomplished by establishing trust and loyalty
among the members of the group. Gardner further states, the sixth task is to accept

FIGURE 3.3 Direct patient care; leadership
at the front line.

72 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

responsibility for ensuring understanding of the vision and mission, specifically as it
relates to individual roles and responsibilities of group members. The seventh task of
the leader is to serve as a role model. Gardner explains, the leader serves as the risk
taker, the group’s voice as well as the force that brings the group together and provides
positivity that they can accomplish their goal. The eighth task of the leader involves
serving as the advocate for the group and their vision; the leader speaks as well as
acts on behalf of the group. The last task of leadership that Gardner speaks to is the
responsibility for ensuring the renewing or sustainability of the group’s mission; this
task is accomplished by balancing continuity with change so that group members do
not become complacent or satisfied with the status quo. The leader helps to maintain
momentum and movement toward accomplishing their goal.

Many changes have occurred in nursing and across healthcare environments
over the past few decades. The landscape and culture of healthcare has emerged
with a new awareness of nurses as leaders in their own right. Nurses are no lon-
ger viewed as being in a dependent role or relationship with the medical disci-
pline but rather collaborative partners to influence policy, practice, and patient
outcomes. Today, nurses lead as patient advocates as they support and provide
patient-centered care practices regardless of nursing education background.
Nurses play a pivotal role in quality to improve the effectiveness of their care.
They are mindful of the technological advances in healthcare and assume lead-
ership roles as informatic super users, managing information to communicate
patient progress and propose care decisions that guide the actions of the health-
care team based on its evaluation.

Nurses lead in promoting a culture of best practices for their patients
and mutually share in organizational goals to justify their services through
empirical, ethical, theoretical, and seminal works across disciplines. Nurses are
influencers as they collaborate with peers in best evidence and care practices,
promote professional practice environments, and adhere to national parameters
that ensure safety and quality outcomes. Today’s nurses at every level are lead-
ers as they assume their role and responsibility to influence others and continue
to transform the landscape of healthcare for future generations.

Esther Bankert, PhD, RN
Board Member, St. Elizabeth’s Hospital, Utica, NY

REAL-WORLD INTERVIEW

A new graduate nurse is eager to be a valuable member of the Dialysis Unit he
has just been hired to work on. He quickly realizes patient safety is a concern
because of short staffing.

1. What is the most pressing concern related to short staffing?
2. What course of action could the nurse pursue to help this situation?
3. What aspects of leadership could he employ to facilitate change?

CASE STUDY 3.1

3 NURSES AS LEADERS AND MANAGERS FOR SAFE, HIGH-QUALITY PATIENT CARE • 73

Formal and Informal Leadership

Leadership within an organization can occur both formally and informally. Formal
leadership involves specific role responsibility and authority related to the position
one holds. This type of leadership is typically based on certain skill, knowledge, and
experience. A variety of formal leadership positions exist within healthcare organi-
zations including nurse executives that might hold positions such as Chief Nursing
Officer or VP of Nursing. Other positions of leadership include a head nurse or charge
leader. Effective leadership exemplifies the qualities of trustworthiness, courage, com-
mitment, and perseverance.

In contrast, informal leadership is not explicit or official. It is based on personal
power or credibility in the eyes of others. This credibility can come from many
sources but typically evolves from education and/or experience as well as from
personal characteristics such as charisma, certainty, and/or courage to speak up or
take action. Nurses at all levels, even newly graduated nurses have the potential
for informal leadership and facilitating positive change by asking question, speak-
ing up when something doesn’t appear right, and engaging in continuous quality
improvement.

MANAGEMENT

Clearly, managers can also be leaders, inspiring and motivating their subordinates.
However, the roles and responsibilities of a manager are distinct and different from
that of formal leaders within an organization. A manager is someone who is respon-
sible for controlling all or parts of an organization. The focus of a manager is getting
the work of the designated group or unit done effectively. As a nurse manager of a
patient care unit, the role and tasks or responsibilities associated with this position
involve the running of a floor or unit and usually include responsibilities such as the
following:

1. The hiring of nursing staff.
2. Creating, reviewing, and amending policies and procedures.
3. Coordinating orientation of new nurses.
4. Creating staffing schedules.
5. Developing and maintaining a budget.
6. Conducting employee evaluations.
7. Providing for professional development.

Roles and Responsibilities of Managers

While the ultimate goal of nurse managers is safe and high-quality patient care, most
often they do not provide direct patient care themselves. Rather, they manage nurses
giving the care, coordinate quality improvement of that care, and help resolve any
patient care concerns. In this role, nurse managers work closely with nursing and
other inter-professional team members including ancillary staff and managers from
other units, departments and disciplines. This list could include individuals from any
department or discipline within the organization, such as pharmacy, physicians and
other providers, as well as administration. Meetings, emails, safety huddles, and other
forms of interaction help the nurse manager to coordinate communication and efforts
of the interprofessional team.

74 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

The list of tasks a nurse manager is responsible for directly and indirectly help
ensure that patient care is both safe and of high quality. They aim to hire qualified staff,
provide adequate staffing to meet their unit’s needs, allow for sufficient resources,
and foster continuous quality improvement. Policies and procedures help to provide
clear expectations to relevant staff. Policies and procedures also provide measures
of performance, knowledge, and skill. As a working document, periodic review and
modifications of policies should occur. This review provides additional opportunity
for continuous improvement.

FOLLOWERSHIP

Not everyone in an organization can be a leader at the same time. And good followers
are just as important as good leaders. Neither exists without each other. A follower is
an individual who supports and is guided by another person who usually functions as
a leader. However, a good follower is not blindly led but rather exhibits traits of dis-
cernment, commitment, and trustworthiness; that is, exhibits similar traits of a leader.
A relationship must exist between the leader and the follower that, to be effective,
must be based on mutual trust and shared goals. As with effective leadership, effective
followership approaches this relationship as equally responsible partners in accom-
plishing the vision and mission at hand. Ideally, followers know their own strengths
and weaknesses as they critically appraise the leader and group’s ideas, thus provid-
ing support and intelligent advocacy.

Shared Responsibility

To be effective leaders, managers, and followers, effective communication is required.
QSEN emphasizes this importance throughout its competencies with specific inter-
ventions/tools such as SBAR and TeamSTEPPS, which are topics discussed in depth
in subsequent chapters.

Chain of Command

Considering the importance of communication to the effective running of any orga-
nization, understanding chain of command is important. Chain of command is the
order or hierarchy of authority within an organization typically delineates flow of
communication and delegation. For example, using a chain of command, a staff nurse
reports to a charge nurse who reports to the head nurse, who in turn might report to
a Department Supervisor. That person might then report to a senior manager who
reports to the VP of Nursing. That VP then typically reports to the CEO who heads the
organization. The chain of command is important for communication and direction of
power. In most institutions and organizations, to initiate or suggest change, follow-
ing the chain of command is a well-established process. For staff nurses, typically the
chain of command starts with their head nurse.

Strategic Planning

Strategic planning and goal setting are based on an organization’s vision and mission.
Many resources exist to aid organizations in developing a strategic plan. One such
resource is the Society for Human Resource Management (SHRM). These resources or
associations help organizations distinguish between similar but different terms. Access

3 NURSES AS LEADERS AND MANAGERS FOR SAFE, HIGH-QUALITY PATIENT CARE • 75

to resources sometimes requires a membership to an organization. SHRM is one of
those associations; however, membership is free and comes with many advantages.
According to SHRM, the vision of an organization is a statement that describes its
ideal or future state, whereas the mission describes why an organization or institution
exists. Based on the vision and mission of an organization, goals are set. Based on the
set goals, the organization will then develop a strategic plan to accomplish them. This
strategic plan typically includes very specific steps, clearly stating who will do what
with exact timelines. Specific units within a hospital will set goals and a strategic plan
that flows from the executive level to them. That is, the unit’s strategic plan helps them
to meet the unit’s goals which support the institution’s goals and strategic plan. QSEN
as well as the FON call nurses to participate in this strategic planning on all levels of an
organization to affect change. This includes sitting on relevant committees and boards
within the healthcare organization as well as within the community in order to partici-
pate equally alongside other interprofessional team members.

FINANCIAL AND ECONOMIC INFLUENCES

Though nursing is in the business of caring, healthcare is clearly a business that must
be financially solvent to exist. As a business, revenue is generated by the care given to
patients. This revenue pays for the expenditures incurred. A budget is an estimate of
anticipated earnings and expenses that allows organizations to plan and function with
forethought. A budget stems from the organization’s mission and goals. While a variety
of budgets exist, most hospitals employ both a capital and an operating budget. A capital
budget focuses on fixed costs such as land and buildings, whereas an operating budget
focuses on day-to-day expenses such as linen and clerical items. An operating budget
typically involves the allocation of resources including those resources involving staff
and needed supplies. Nursing units normally function with an operating budget that
focuses on salaries and supplies required for the care the unit provides (Sherman, 2012).

Incoming Revenue

The revenue of an organization comes from reimbursement paid for patient care.
Reimbursements come from insurance companies, governmental agencies, and out-
of-pocket payments made by the patient. If a hospital is fortunate to conduct research
and/or allow for auxiliary boards, unique and separate sources of funding or money
can augment what is received in reimbursements.

Up until more recently, healthcare reimbursement has been tied to patient care
provided in a fee-for-service model. A fee-for-service model of reimbursement pays a

Samantha is a nurse manager of a busy neuro floor. She has noticed a steady
decline in patient satisfaction rates.

1. Should she ignore this situation?
2. How should Samantha approach this matter with her staff?
3. How could Samantha’s supervisor help her with this matter?

CASE STUDY 3.2

76 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

provider or institution for each individual or separate component of care, independent
of quality or patient satisfaction. However, healthcare reimbursement is now based on
additional factors such as patient outcomes (how well did the patient respond to the
care provided?) as well as patient satisfaction measures. These additional performance
measures alongside decreased reimbursements from many private and public insurers
have tightened hospital’s and organization’s budgets significantly.

Staffing

Misuse of finances within the healthcare setting can have dramatic consequences on indi-
vidual patients as well as on the institution. As professionals responsible for patient care,
nurses have a moral obligation to understand how finances impact their ability to do their
jobs safely, including how budgets affect staffing, which in turn affects patient care. In fact,
studies show that patient mortality and morbidity is directly affected by the number of
patients assigned to a nurse in a given shift. The number of patients assigned to a nurse
depends on staffing of the unit. Staffing can be centralized where one unit or department is
responsible for determining the needs for all units. Staffing can also be decentralized where
the individual unit or department determines its specific staffing needs. Typically, staffing
needs are expressed in a ratio of nurses to patients, which can be determined by one or
more factors including budget allocation, beds filled, and patient acuity (Mensik, 2014).
An example of this ratio on a medical–surgical floor might be one nurse to 24 patients or a
1:3 ratio. Adequate staffing helps to ensure nurses are able to provide safe and high-qual-
ity care. Organizations like the Agency for Healthcare Research and Quality: Advancing
Excellence in Healthcare and Planetree.org provide valuable tools to nurses and healthcare
organizations to use for many aspects of healthcare, including safe staffing.

In 2004, California became the first state to mandate minimum nurse–patient
ratios. The legal mandate was limited to the following ratios:

• 6:1 patient-to-nurse workload in psychiatrics
• 5:1 patient-to-nurse in medical–surgical units, telemetry, and oncology
• 4:1 in pediatrics
• 3:1 in labor and delivery
• 2:1 in ICUs

Aiken et al. (2010) studied the impact of this mandate on patient outcomes and found
it significantly improved patient outcomes and nurse retention.

Ensuring that the competencies of QSEN are implemented has been shown to save
hospitals money. For example, cost savings have been demonstrated with the provi-
sion of patient-centered care. See the Evidence From the Literature for one such study.

CRITICAL THINKING 3.1

A nurse has been working on an oncology floor for 1 year. At times she feels frustrated
that concerns regarding patient safety are not being taken seriously. She cares deeply for
her patients as well as the floor itself and believes she could make a difference as a more
formal leader. When an opening for a nurse manager position opens up, she applies for
and gets the position.

(continued)

3 NURSES AS LEADERS AND MANAGERS FOR SAFE, HIGH-QUALITY PATIENT CARE • 77

EVIDENCE FROM THE LITERATURE

Citation

Wong, C. A., Cummings, G. G., & Ducharme, L. (2013). The relationship between
nursing leadership and patient outcomes: A systematic review update. Journal of
Nursing Management, 21(5), 709–724.

Discussion

A systematic review of existing studies was undertaken to examine the rela-
tionship between the practice of nursing leadership and patient outcomes. The
authors identified 20 articles documenting the study of this relationship. They
found a distinct correlation between positive, effective leadership and bet-
ter patient outcomes. The specific leadership qualities found to most effective
were positive, relationship based, and transformational, and reflected organiza-
tional goals and missions. Patient outcomes of this positive leadership included
improved patient satisfaction and decreased mortality, medication errors, noso-
comial infections, and use of patient restraints.

Implications for Nursing: Patient safety and quality of care is affected by
leadership. Therefore, efforts to encourage leadership of nurses at all levels of
practice are warranted.

CRITICAL THINKING 3.1 (continued)

1. How could her understanding of Quantum Leadership Theory guide her in
her new role?

2. How might she ensure staff feel heard?
3. In what other ways can she help staff be effective leaders?
4. In what ways can she help staff be effective followers?

Maria works as a staff nurse on a medical–surgical floor. She is asked to join
a new committee focused on improving communication between the various
departments providing care on her floor. The committee is led by a dynamic and
inspiring pharmacist.

1. How is Maria a leader in this scenario?
2. How is she a follower?
3. How could her understanding of Chaos Theory helps her in this scenario?

CASE STUDY 3.3

78 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

NURSING’S SOCIAL CONTRACT AND CODE OF ETHICS

Nurses’ right and authority to practice as nurses are based on an ethical social contract
with society that explicates specific rights and responsibilities based on education and
licensure. Within this contract, nursing describes and agrees to the essence of the profes-
sion with clear guidelines for behavior and intention. Documented as Nursing’s Social
Policy Statement, the relationship between nursing (and individual nurses within the
profession) and society is explained and spelled out. The behaviors expected of nurses
are based on autonomy to function and perform within the scope of nursing practice.
The autonomy of nurses is in turn based on nursing’s acknowledgment of public trust as
well as nursing’s agreement to self-regulate and accept legal parameters and regulations.

Within the social contract is a Code of Ethics for Nurses that lists nine provi-
sions. These provisions allow nurses to fulfill the commitment made to their patients.
However, it also guides nurses to effectively serve as leaders in any and all positions.
The nine provisions are the following:

• The nurse practices with compassion and respect for the inherent dignity, worth,
and unique attributes of every person.

• The nurse’s primary commitment is to the patient, whether an individual, family
group, community, or population.

• The nurse promotes, advocates for, and protects the rights, health, and safety of
the patient.

• The nurse has authority, accountability, and responsibility for nursing practice;
the nurse makes decisions and takes action consistent with the obligation to pro-
mote health and to provide optimal care.

• The nurse owes the same duties to self as to others, including the responsibility to
promote health and safety, preserve wholeness of character and integrity, maintain
competence, and continue personal and professional growth.

• The nurse, through individual and collective effort, establishes, maintains, and
improves the ethical environment of the work settings and conditions of employ-
ment that are conducive to safe, quality healthcare.

• The nurse, in all roles and settings, advances the profession through research and
scholarly inquiry, professional standards development, and the generation of both
nursing and health policy.

• The nurse collaborates with other health professionals and the public to protect
human rights, promote health diplomacy, and reduce health disparities.

• The profession of nursing collectively through its professional organizations
must articulate nursing values, maintain the integrity of the profession, and inte-
grate principles of social justice into nursing and health policy (American Nurses
Association, 2015).

CRITICAL THINKING 3.2

Your hospital is hosting the next FON: Campaign for Action in your area. You express
interest in attending the meeting; however, your nurse manager denies your request
because the floor will be short staffed.

1. What options do you have in response to this decision?
2. In this scenario, how can you be an effective informal leader?
3. In this scenario, how can you be an effective follower?

3 NURSES AS LEADERS AND MANAGERS FOR SAFE, HIGH-QUALITY PATIENT CARE • 79

To Be a Profession

In the mid-1980s, reimbursement for patient care moved from a retrospective reim-
bursement system or fee-for-service to one of prospective payment. Reimbursing for
care prospectively meant providers and hospitals were paid based on standardized
care related to a patient diagnosis. Diagnostic-related group formulas (DRGs) were
created as a way to control hospital costs, which represented a way to “capitate” or
control costs. At the time, some nurse leaders believed it provided an opportunity for
nursing to become more visible. Because patients are admitted to the hospital for nurs-
ing care, it was hoped DRGs would emphasize the centrality of nursing. Along with
this realization, it was thought nursing would also move into a position of more author-
ity. At the time, a revered nurse leader Donna Diers (1986) addressed District Four of
the New York State Nurses Association. The title of her speech was “To Profess—To Be
a Professional.” She began by explaining the meaning of “to profess,” which infers a
dishonesty or insincerity of beliefs. She argued nurses were and are professional; how-
ever, she also stated nurses had not yet obtained the authority for the responsibility
they had been delegated. Like others, she spoke of the social contract nurses have with
their patients and society. She also spoke of nursing’s primacy of caring. Diers believed
the DRGs were the start of a revolution that offered nurses the opportunity to step into
a place of authentic and deserved authority. Nurse’s moral imperative is to care. But
simply providing care or exerting compassion and concern are not enough. Diers and
many others throughout nursing’s history have argued caring must be intelligent and
intentional. She states:

Nursing is not just comfort, care, coordination, collaboration, or just applied psy-
chology, physiology, sociology, anthropology or diluted medical science. Nursing
is all of those things and more. It requires an effort of considerable intellectual
acuity—which looks to an outsider like intuition—to thread one’s way through
all the knowledge, technique, and tenderness one has and to come out with the
right action to serve the patient’s particular need. (Diers, 1986, p. 27)

Like many of her contemporary counterparts, Diers acknowledged that the applica-
tion of caring must extend from individual patient care to the creation of budgets,
committees, curricula, community efforts, and legislative work. However, what she
argued most ardently was nurses’ legitimacy as professionals would not come from
advanced degrees or credentialing. Rather, Dier’s proposed, nursing’s professionalism
and authority would be established when nursing’s practice was professional. She
argued this would only happen if and when nurses took ownership of the work per-
formed once education occurred.

This argument has been made by many others over time, both within as well as
outside the nursing profession. Suzanne Gordon is another powerful and ardent cham-
pion of nursing and nurses’ need to “own the knowledge of their work.” Ms. Gordon is
a journalist who has become a nationally recognized expert in healthcare systems but
specifically on teamwork, nursing, and patient safety. She is a prolific author, speaker,
and advocate/activist. Like Diers, Gordon argues nurses are solely responsible for
how they are viewed in her 2006 landmark book authored with Bernice Buresch, From
Silence to Voice:

If nurses aren’t willing to talk about their work, the results will be catastrophic
for nursing. Nursing, like every other profession in today’s work, must justify its
existence and compete for resources. If nursing is misunderstood by the public
and those with influence, it will continue to be disproportionately vulnerable to

80 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

the budget ax, and new resources for nursing education and practice will not be
forthcoming at sufficient levels.

If nursing’s script continues to emphasize the virtues of the nurse as a person
to the detriment of the knowledge work that nurses do, then nurses themselves
offer a rationale for limiting resources for nursing. Focusing on who the nurse is
rather than what the nurses does can be an invitation to seek not the best and the
brightest recruits, but the most virtuous, meekest and self-sacrificing who will
try to do more and more with less and less. (p. 4)

EMANCIPATORY KNOWING

Acknowledging and accepting responsibility for the knowledge required to do the work
of nursing is an important start. But knowledge is based on knowing, which speaks
to subjective perception and a dynamic ontology or way of being. When knowing is
expressed in a way that can be shared, it is considered to be knowledge. Knowledge
of a discipline, such as nursing, encompasses the body of shared knowledge. This pro-
cess of sharing knowledge within a discipline is vital to the creation of a community.
According to Chinn and Kramer (2013), once knowledge moves beyond the individual
to the discipline as a group, “social purposes form, and knowledge development and
shared purposes form a cyclical interrelationship that moves us toward perspective,
value-grounded change or praxis” (p. 4). For Chinn and Kramer, praxis is the outcome of
critical thought and reflection of the art and science of nursing. Change occurs with the
inclusion of ethics and the therapeutic use of self that ultimately results in some type of
action. This process of thinking and reflection that leads to action is called Emancipatory
Knowing.

As with Chaos and Quantum Theories, Emancipatory Knowing stems from criti-
cal evaluation of economic, social, and political influences of a reality or status quo
simultaneously looking at its potential for positive change. For Chinn and Kramer, this
positive change must involve alleviating injustice in order to ensure equitable condi-
tions for individual and groups. In doing so, individuals and groups are provided the
opportunity to fulfill their potential.

FON: CAMPAIGN FOR ACTION

As discussed earlier, the IOM reports of 2000 and 2001 have led to many initiatives,
including the formation of the FON: Campaign for Action. Within this initiative, sev-
eral organizations joined forces to support nurses in a unique way. The RWJF, AARP,
and the AARP Foundation pledged their support and resources to aid the nursing

CRITICAL THINKING 3.3

You work on a busy pediatric floor. During casual conversation with colleagues, you
realize medication errors are increasing significantly.

1. How could you proactively respond to this realization?
2. With whom should you first begin discussing this realization?
3. Who else should be involved in assessing and addressing this situation?

REAL-WORLD INTERVIEW

3 NURSES AS LEADERS AND MANAGERS FOR SAFE, HIGH-QUALITY PATIENT CARE • 81

profession in addressing the eight recommendations listed earlier. While the FON
acknowledges the importance of all recommendations, they identified four specific
or key elements to ensuring all nurses will be prepared to assume a leadership role
within institutions and healthcare as a whole (Box 3.2).

Nurses entering the profession often voice their reason for choosing nursing as a
desire to “make a difference” by impacting or facilitating another’s physical and
mental well-being. Through helping others, a challenge develops that offers the
nurse an opportunity to grow morally, ethically, and spiritually. The challenge is
the quest for “doing the right thing” for the patient. This implies that the nurse
must be responsible for developing therapeutic alliances, monitoring and evalu-
ating patient needs, as well as ensuring interventions have produced the intended
results and outcomes. This further implies that nurses must be successful in criti-
cally questioning and then identifying necessary changes, within their own nurs-
ing practice, as well as using their leadership skills in the development of teams
that promote evidence-based practice with patient-focused care and goals.

Nurses’ growth and experience in providing quality care happens over
time. Quality is achievement, refinement, and satisfaction in and of practice,
but the quest to become “REAL” requires a continuous commitment to the
very process that is often infused with the challenges that we ethically, morally,
and spiritually need to address in order to “become.” Rising to the challenge
requires developing leadership skills in defining and critically analyzing what
is inherent in quality nursing practice; for example, doing a nursing interven-
tion because it is the “right thing to do” and not because that “is how it has
always been done.” Essential to achieving best outcomes requires that:

• Quality, the quest for best practice, becomes the way we do business.
• Mentors for quality who are respected clinicians and knowledgeable role

models with moral courage will step forward when necessary to serve as
patient advocates and to promote quality care endeavors, such as critically
questioning, investigating, and promoting nursing practice in the ever-
changing healthcare arena.

• Academic nursing programs support clinical experiences with practicing
nurses that routinely incorporate quality behaviors on the front line and
embrace quality endeavors as the main approach to promoting best outcomes.

• Reinforcement of quality and change theory principles in continuing edu-
cation for all healthcare professionals and the expectation that these prin-
ciples be used by all in the patient-centered setting.

If we choose to make a committed difference individually, what follows is
the collective commitment to quality and safe nursing practice that offers the
nurse, patient, team, and health administrative staff the best care.

Judy Kilpatrick, RN, MS, CCNS, ANP
Syracuse, NY

Denise A. Karsten RN, MS, DC, Adult/Gero Nurse Practitioner
Primary Spine Practitioner

Upstate Brain and Spine Center
Syracuse, NY

REAL-WORLD INTERVIEW

82 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

The call to action by multiple nurse leaders and organizations is clear: Nurses must
step into leadership positions at all levels of practice. From advocating for the primary
prevention of nosocomial infections to safer staffing to working on committees to refine
policies ensuring safer and higher quality patient care on units, in institutions, and on
more global levels, nursing can have a powerful and important role to play. Nursing’s
social contract requires nursing to engage in a more global systems thinking that
embraces moral courage and the knowing of its profession. By doing so, nursing will
step into leadership that influences the safety and quality of care of patients individually
and as a whole.

KEY CONCEPTS

1. Nursing education must prepare nurses to demonstrate leadership at all levels of
nursing practice, directly and indirectly impacting the safety and quality of patient
care.

2. Three theories of leadership that guide nursing practice are Chaos Theory,
Quantum Theory, and Systems Theory.

3. Leadership is the ability to lead or command a person or a group of people.
4. The roles of a leader typically involve developing a vision and facilitating change

on a large scale, such as for a department or institution.
5. A manager is someone responsible for controlling all or part(s) of an organization,

and for getting a designated group or unit’s work done effectively.
6. A follower is an individual who supports and is guided by a leader, who shares

mutual trust and goals with the leader, and who is an equally responsible partner
in accomplishing the vision and mission at hand.

7. Nursing care must be provided within the context of the business of healthcare. It
must generate revenue and operate within the constraints of the budget.

8. Nursing practice is based on an ethical social contract with society that expli-
cates specific rights and responsibilities of nurses, such as those embodied in the
Nursing Code of Ethics.

9. Nursing practice should be guided by emancipatory knowing, which is a process
of thinking and reflection that leads to action.

1. Nurses should practice to the full extent of their education and training.
2. Nurses should achieve higher levels of education and training through an improved

education system that promotes seamless academic progression.
3. Nurses should be full partners with physicians and other health professionals in

redesigning healthcare in the United States.
4. Effective workforce planning and policy making require better data collection and an

improved information infrastructure (IOM, 2011, p. 58).

BOX 3.2 KEY ELEMENTS

3 NURSES AS LEADERS AND MANAGERS FOR SAFE, HIGH-QUALITY PATIENT CARE • 83

10. The FON: Campaign for Action is an initiative in which several organizations have
joined forces to support nurses and prepare them to assume leadership roles with
institutions and healthcare as a whole.

KEY TERMS

Accountability
Follower
Leadership

Manager
Responsibility
Roles

REVIEW QUESTIONS

1. The nurse is working on a busy medical–surgical floor caring for oncology
patients. One of the patients with a poor prognosis is asking for a glass of wine
with dinner. The floor policy states that patients are not allowed to consume alco-
hol while admitted to their floor. The nurse believes the policy as stated does not
take into consideration the circumstances this patient is experiencing. The nurse
approaches the manager with a request to review and potentially modify the cur-
rent policy. The manager agrees a review of the policy is warranted but would like
the nurse to invite several other interdisciplinary team members to the meeting in
order to consider their perspective. The manager specifically invites them to this
discussion because they understand the impact allowing alcohol could have on
departments such as Dietary, Pharmacy, and Physical Therapy. What leadership
theory explains the manager’s perspective most accurately:

A. Chaos
B. Quantum
C. Change
D. Systems

2. A nurse decides to apply for a hospital leadership position after receiving a glow-
ing performance review at her fifth year anniversary as a floor manager. The nurse
is aware that a formal leadership position will include unique roles and responsi-
bilities. Which of the following apply to leadership (distinguished from manage-
ment)? Select all that apply.

___ Improve on ways an organization functions to meet its goals and objectives.
___ Conducts periodic review of unit policies and procedures.
___ Develop skills in managing conflicts of different groups with differing

priorities.
___ Enforce policies such as continuing education requirements for nursing staff.
___ Focus on the long term.
___ Identify areas for marketing campaigns to increase income, thus increasing

staffing.
___ Create the staffing schedule for the medical–surgical unit.
___ Actualize and demonstrate the organization’s mission by motivating others.
___ Lead by displaying your education and professional certifications to inspire

others.

84 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

3. A nurse applies for a position as a unit manager. In the interview process, the
nurse is asked to list responsibilities they assume will come with the position. List
three tasks that could be included in this list:

A. _______________________
B. _______________________
C. ________________________

4. A nurse has just taken a new position on an orthopedic floor as a staff nurse. Before
this new position, the nurse had been a Team Leader on the Telemetry Unit for almost
5 years. In this new position and role, the nurse is aware that being a follower is a
vital piece of demonstrating an organization’s mission and values. The nurse also
understands that all nurses are followers and leaders, often at the same time. How
can the nurse best demonstrate followership in this new role? Select all that apply:

___ Demonstrate the organization’s missions and values in patient care.
___ Know the strengths and weaknesses that you bring to both roles.
___ Challenge every suggestion the group leader makes.
___ Build relationships with those you follow.
___ Only accept tasks that are of personal interest.
___ Recognize that followers always support their leaders.

5. The nurse works for a hospital that is experiencing budget cuts and layoffs due
to decreased reimbursements. The nurse is concerned about how this might affect
patient care. What potential ramifications should the nurse be concerned about?
Select all that apply.

___ Poor staffing ratios
___ Use of unqualified staff
___ Increased patient satisfaction
___ Fewer supplies on the unit
___ Hiring freezes
___ Poor patient outcomes

6. The nurse is asked to work overtime because replacements have not been hired yet
to fill recent vacancies. The nurse is very concerned about agreeing to this over-
time, because the shift is already down two nurses. The nurse is also concerned
because the hospital is freezing budgets and most likely will not fill these vacant
positions for a while. What outcome is the nurse concerned about relative to safety
and quality of care? What factor in a hospital budget has the most direct effect on
patient morbidity and mortality?

________________________________________

7. The nurse is attending general orientation with a group of new graduates. A clini-
cal nurse specialist (CNS) presents a 1-hour talk on professionalism and respon-
sibility to function as leaders in the new positions the nurses will assume. Within
this presentation, the CNS states all nurses practice within a Code of Ethics and
agree to a social contract with society. What are the components of Nursing’s Code
of Ethics? Select all that apply.

___ Compassion
___ Patient dignity
___ Commitment to the patient

3 NURSES AS LEADERS AND MANAGERS FOR SAFE, HIGH-QUALITY PATIENT CARE • 85

___ Protecting patient rights
___ Health and safety
___ Promotion of health
___ Participating in improving ethical environment in care setting and/or larger

community
___ Collaborating with others to establish/maintain standards, articulate values,

and generate policy

8. Jim, a nurse, has volunteered to sit on a professional development committee as a
representative from the floor he works on. In one of the first committee meetings,
Jim is asked what he would be interested in knowing more about. Jim explains he
is confused about the meaning of autonomy. Which of the following is false?

A. Autonomy refers to delegating responsibility to others.
B. Autonomy refers to the right to self-regulate or govern.
C. Autonomy in nursing has been earned by society’s trust.
D. Autonomy in nursing includes legal parameters delineating scope of practice.

9. Mary works as a nurse in an NICU with a few unhappy colleagues. Unfortunately,
the demeanor of these few nurses affects many people, including the parents of
the neonates. Mary knows the impact of stress on these vulnerable families and
infants so she begins to explore how to change the situation. In researching ideas,
Mary discovers an intervention that might help and reflects on the interpersonal
dynamics of the unit alongside the complexity of the health of its patients. Mary
considers each person’s right to self-determination and autonomy and also con-
siders how best to approach proposing change. Ultimately, the thought, reflection,
and therapeutic use of self leads to deliberate action by Mary, facilitating effective
change. What is this process called?

________________________________________

10. A nurse is orienting to a new position on a transplant floor. Part of the job expec-
tations includes serving on committees. The nurse is interested in promoting the
nursing profession, particularly as it relates directly and indirectly to ensuring
safe and high-quality patient care. As such, the nurse is interested in joining the
local Action Coalition of the FON: Campaign for Action. Because this activity will
require quite a bit of time off the unit, the nurse will need to provide a brief expla-
nation of this initiative. As a foundation, the nurse lists the four key elements of
the FON. Please list two of the four elements:

A. ____________________
B. ____________________

REVIEW ACTIVITIES

1. Consider how the Key Elements of the FON, Campaign for Action could help you
as a nurse leader in your first position as a staff nurse.

2. How does the Nursing Code of Ethics impact how you will practice as a new nurse?
3. What characteristics of leadership do you bring to the frontline of patient care?

86 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

CRITICAL DISCUSSION POINTS

1. Leadership theories provide effective guidance in understanding how best to facili-
tate change.

2. The roles and responsibilities of leaders directly and indirectly affect the safety as
well as the quality of patient care.

3. Management incorporates aspects of leadership but is primarily focused on getting
the work of an assigned group accomplished.

4. Being an effective follower includes critical thinking, commitment to the group’s
goals, and mutual trust.

5. The FON: Campaign for Action is a national initiative that provides a forum for
collaborative effort aimed at empowering the nursing profession.

6. Staffing directly affects patient satisfaction surveys but more importantly, patient
outcomes.

7. Staffing adequacy is based on a sufficient budget.
8. Nursing’s Code of Ethics provides guidance for practice and action.
9. Emancipatory Knowing requires one to integrate critical thought, reflection, ethics,

and therapeutic use of self within a community created by shared knowledge. This
integration leads nurses to take action and facilitate change at all levels of practice.

EXPLORING THE WEB

1. Visit QSEN.org and review the various Graduate QSEN Competencies, specifically
noting the knowledge, attitude, and skill for each of them. Reflect on which of these
competencies you feel comfortable with at this time. Consider which you feel are
essential to have acquired before you start as a graduate nurse.

2. Visit the following websites to compare and contrast resources: Agency for Healthcare
Research and Quality: Advancing Excellence in Healthcare and Planetree.org.

3. Search the Internet for how the FON is referenced and incorporated into action
plans within nursing and as an interprofessional approach to change.

4. Conduct an Internet search for the terms “leadership” and “nursing.” Describe
what your search reveals.

REFERENCES

Aiken, L. H., Sloane, D. M., Cimiotti, J. P., Clarke, S. P., Flynn, L., Seago, J. A., … Smith, H. L.
(2010). Implications of the California nurse staffing mandate for other states. Health Services
Research, 45(4), 905.

American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. Silver
Spring, MD: American Nurses Association.

Buresh, B., & Gordon, S. (2006). From silence to voice: What nurses know and must communi-
cate to the public (2nd ed). Ithaca, NY: ILR Press/Cornell University Press.

Chinn, P. L., & Kramer, M. K. (2013). Integrated theory and knowledge development in nursing (7th
ed.). St. Louis, MO: Mosby Elsevier.

Curtis, E. A., de Vries, J., & Sheerin, F. K. (2011). Developing leadership in nursing: Exploring
core factors. British Journal of Nursing, 20(5), 306–309.

Diers, D. (1986). To profess—To be a professional. Journal of Nurse Administration, 16(3), 25–30.
Dinh, J., Lord, R. G., Gardner, W. L., Meuser, J. D., Liden, R. C., & Hu, J. (2014). Leadership theory

and research in the new millennium: Current theoretical trends and changing perspectives.
The Leadership Quarterly, 25(1), 36–62.

3 NURSES AS LEADERS AND MANAGERS FOR SAFE, HIGH-QUALITY PATIENT CARE • 87

Dolansky, M. A., & Moore, S. M. (2013). Quality and safety education for nurses (QSEN): The
key is systems thinking. The Online Journal of Issues in Nursing, 18(3), 1–10. Retrieved from
www.nursingworld.org/Quality-and-Safety-Education-for-Nurses.html

Gardner, J. (1993). On leadership. New York, NY: The Free Press.
Grossman, S. C., & Valiga, T. M. (2016). The new leadership challenge: Creating the future of nursing

(5th ed.). Philadelphia, PA: F.A. Davis.
Institute of Medicine (IOM). (2011). The future of nursing: Leading change, advancing health.

Washington, DC: The National Academies Press.
Mensik, J. (2014). What every nurse should know about staffing. American Nurse Today. Retrieved

from www.americannursetoday.com/what-every-nurse-should-know-about-staffing
Oxford Dictionary. (2017). Integrity. Retrieved from https://en.oxforddictionaries.com/

definition/integrity
Porter-O’Grady, T., & Malloch, K. (2011). Quantum leadership: Advancing innovation, transforming

health care (3rd ed.). Sudbury, MA: Jones & Bartlett Learning.
QSEN. (2017). QSEN institute: Quality and safety education for nurses. Retrieved from www.

qsen.org
Sherman, R. (2012). The business of caring: What every nurse should know about cutting costs.

American Nurse Today. Retrieved from www.americannursetoday.com.
Society for Human Resource Management (SHRM). (2017). Mission & vision statements: What

is the difference between mission, vision and values statements? Retrieved from https://
www.shrm.org/

SUGGESTED READINGS

AHRQ. (2016). AHRQ patient safety tools and resources. Retrieved from http://www.ahrq.gov/pro-
fessionals/quality-patient-safety/patient-safety-resources/resources/pstools/index.html

American Nurses Association. (2010). Nursing’s social policy statement: The essence of the profession.
Silver Spring, MD: American Nurses Association.

Anderson, C. L., & Agarwal, R. (2011). The digitalization of health care: Boundary risk, emotion,
and consumer willingness to disclose personal health information. Information Systems Research,

22(3), 469–490.
Bertakis, K. A., & Azari, R. (2011). Patient-centered care is associated with decreased health care

utilization. Journal of the American Board of Family Medicine, 24, 229–239.
Chinn, P. L. (2013). Peace and power: New directions for building community. Burlington, MA: Jones

and Bartlett Learning.
Fischer, S. A. (2016). Transformational leadership in nursing: A concept analysis. Journal of

Advanced Nursing, 72(11), 2644–2653.
Hughes, R. G. (2008). Patient safety and quality. Rockville, MD: Agency for Health Care Research

and Quality.
Kreidler, M. L. (2015). Quality improvement in health care. Research Starters: Business (Online

Edition).
Nadeem, E., Olin, S., Hill, L., Hoagwood, K., & Horwitz, S. (2013). Understanding the compo-

nents of quality improvement collaboratives: A systematic literature review. Milbank Quar-
terly, 91, 354–394.

National Committee for Quality Assurance. (2007). About NCQA. Retrieved from http://www.
ncqa.org/AboutNCQA.aspx

The National Academies of Press. (2011). The future of nursing: Leading change, advancing
health. Retrieved from http://www.nap.edu/read/12956/chapter/10#235

Wong, C. A., Cummings, G. G., & Ducharme, L. (2013). The relationship between nursing Lead-
ership and patient outcomes: A systematic review update. Journal of Nursing Management,
21(5), 709–724.

Wong, C. A., Lashchinger, H. K., & Cummings, G. G. (2010). Authentic leadership and Nurses’
voice, behavior, and perceptions of care quality. Journal of Nursing Management, 18, 889–900.

Upon completion of this chapter, the reader should be able to

1. Define high-reliability organizations (HROs).

2. Evaluate the characteristics of HROs.

3. Describe how high reliability affects all aspects of an organization.

4. Identify how healthcare can learn about high reliability from other industries.

5. Analyze healthcare system changes essential for HRO.

6. Discuss nursing responsibilities and interprofessional team functions required
for achieving high reliability.

7. Compare and contrast methods for assessing a culture of high reliability.

8. Discuss barriers to achieving high reliability.

9. Identify internal and external resources helpful in an organization’s journey to
high reliability.

4
QUALITY AND SAFETY IN
HIGH-RELIABILITY ORGANIZATIONS

Patti Ludwig-Beymer

Every system is perfectly designed to get the results it gets. (Attribution disputed)

90 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

A
patient who was discharged postabdominal surgery at General Hospital returned
a week later with sepsis from a surgical site infection. During her rehospitalization,
x-rays revealed that a sponge was retained in her abdomen during the initial surgical
procedure. By definition, this is a sentinel event, and it is thoroughly investigated by a

team that includes nurses, physicians, surgical technicians, anesthesiologists, and staff from risk
management and quality. The team conducts a root cause analysis to determine the underlying
cause of the retained sponge and to create a corrective action plan. The sentinel event is reviewed
and the corrective action plan is approved by hospital leadership and governance. Everyone at
the hospital expresses confidence that the processes put into place will prevent this event from
happening again. Unfortunately, within a few months, a sponge is retained in another patient’s
abdomen after a gynecological surgical procedure.

• How could this sentinel event error happen again?
• What unit or organizational characteristics may have contributed to this sentinel event?
• What can the interprofessional healthcare team do to prevent future errors?

In To Err Is Human, the Institute of Medicine (IOM;1999) described the safety of
healthcare in the United States and suggested that up to 98,000 people die in hos-
pitals each year as a result of medical errors that could have been prevented. To Err
Is Human provided a roadmap to safety, including strategies to enhance knowledge
about safety; identifying and learning from errors; raising expectations for improv-
ing safety; and implementing safety systems in healthcare organizations to ensure
safe practices at the patient care delivery level. Unfortunately, errors that cause harm
to patients continue to occur.

More recently, Makary and Daniel (2016) estimated medical errors cause 251,000
deaths each year, making it the third leading cause of death in the United States, after
heart disease and cancer. Yet medical error is not even recorded on U.S. death certifi-
cates. Most medical errors do not result from individual recklessness or the actions of
a particular group but are instead caused by faulty healthcare systems, processes, and
conditions that lead people to make mistakes or fail to prevent them. As a result, mis-
takes can best be prevented by designing the health system to make it easier to do the
right thing and harder to do the wrong thing.

Makary and Daniel propose a three-part model for reducing harm from individual
and system errors: (a) transparency to make errors more visible, (b) rapid response
to errors, and (c) decrease the frequency of errors. Transparency is defined as openly
sharing and making errors and other aspects of performance visible so that everyone
can learn from the errors and improve quality. Within the model, the responsibility for
reducing harm lies with both the organization and the individual.

The Joint Commission (TJC, 2017), an independent, not-for-profit group in the
United States that administers voluntary accreditation programs for hospitals and
other healthcare organizations, adopted a formal Sentinel Event Policy in 1996 to
help hospitals that experience serious adverse sentinel events improve safety and
learn from those sentinel events. A sentinel event is a healthcare error that reaches
a patient and results in death, permanent harm, or severe temporary harm and
requires healthcare interventions to sustain life. A sentinel event requires immediate
investigation and response by the interprofessional healthcare team to prevent it
from happening again.

Each year, TJC publishes a list of the most frequent sentinel events that occurred
nationally (Box 4.1). TJC recommends, but does not require reporting of sentinel
events. As a result, this published sentinel events list represents only a fraction of the

4 QUALITY AND SAFETY IN HIGH-RELIABILITY ORGANIZATIONS • 91

actual number of sentinel events. Careful investigation and analysis of sentinel events
and other patient safety events and creation of corrective actions are essential to reduc-
ing risk and preventing patient harm.

This chapter focuses on building a high-reliability organization (HRO), a cultural
transformation designed to ensure safe practices and reduce errors and sentinel events
in healthcare. The chapter begins by defining HROs and presenting the characteristics
of HROs. The effect of high reliability on all aspects of an organization is described.
Healthcare changes essential for creating HROs are discussed, and the nurse’s responsi-
bilities required for achieving high reliability are described. The importance of interpro-
fessional team function is addressed. Finally, barriers to achieving high-reliability and
internal and external resources helpful in a journey to high reliability are summarized.

HIGH-RELIABILITY ORGANIZATIONS

HROs, such as commercial aviation and nuclear power plants, operate under very
trying conditions all the time and yet manage to have fewer than their fair share of
accidents. HROs in healthcare establish and maintain high quality and safety expec-
tations for patient care and keep quality and safety error rates near zero (Weick &
Sutcliffe, 2007). HROs have the ability to provide consistent healthcare at a high
level of excellence over a long period of time. Reliability is defined as the prob-
ability of failure-free performance over a specified timeframe. It is also called quality
over time (www.businessdictionary.com/definition/reliability.html). Morrow (2016)
describes reliability as “getting the expected outcome throughout the expected time”
(p. 9). The risk of healthcare error is a function of both probability and consequence.

Healthcare can be dangerous and errors can have devastating consequences. For
example, administering IV fluids safely is an important aspect of treating a dehydrated
patient who has heart failure. Administering fluids too slowly can result in prolonged
hypotension. Administering fluids too rapidly can result in worsening of the heart
failure. An IV pump is used to assist the nurse in providing accurate amounts of
fluid. The IV pump decreases the probability of error. However, if the pump fails, the

1. Unintended retention of a foreign body—116 reported
2. Wrong patient, wrong site, wrong procedure—95 reported
3. Falls—114 reported
4. Suicide—89 reported
5. Unassigned (category unassigned at time of report)—54 reported
6. Delay in treatment—66 reported
7. Other unanticipated event (including asphyxiation, burn, choked on food, drowned,

or found unresponsive)—60 reported
8. Operative/postoperative complication—19 reported
9. Medication error—32 reported

10. Criminal event—37 reported

BOX 4.1 TOP 10 SENTINEL EVENTS IN THE UNITED STATES, 2017

Source: The Joint Commission (TJC). (2018). Summary data of sentinel events reviewed by The Joint Commission. https://www.
jointcommission.org/assets/1/18/Summary_4Q_2017.pdf

92 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

consequences can still be catastrophic. By decreasing the probability of an error, HROs
operate to make healthcare systems safer. In an HRO, a culture of safety permeates the
organization, and everyone is expected to ensure safety.

To improve safety, HROs maintain a focus on reducing errors. An error is a devia-
tion from generally acceptable performance standards. Generally acceptable perfor-
mance standards are found internally within a healthcare organization and externally
outside of an organization. Internal standards include policies, procedures, proto-
cols, and order sets. External standards include healthcare industry and accreditation
imposed practice requirements and professional practice standards. For example, a
hospital may establish a protocol that requires a nurse to assess an IV infusion site
in pediatric patients every 2 hours. This is an internal standard. On the other hand,
the American Association of Critical-Care Nurses (2015, p. 14) requires that the nurse
“intervenes to prevent and minimize complications and alleviate suffering.” If the
nurse fails to assess a patient on a ventilator and provide sedation and pain medica-
tion as needed, the nurse has deviated from generally acceptable external performance
standards.

A deviation from performance standards may cause varying levels of harm to a
patient. A near miss safety event occurs when the safety event does not reach the
patient because it is caught by chance or because the process was engineered with a
detection barrier. For example, the medication reconciliation process in hospitals is
often designed with purposeful redundancies. On admission, a nurse or pharmacist
meets with a patient to obtain an accurate list of current medications. The physician
then reviews the list, verifies it with the patient, and places the medication orders.
A pharmacist reviews the medications, and the nurse administers the medications.
Despite these steps, sometimes an incorrect medication is ordered. If this is discov-
ered before the medication is administered, it is considered a near miss event. Nurses
and other clinicians may fail to report near misses, rationalizing that no one was hurt.
However, near miss safety events serve as an early warning system of something that
could go wrong. By reporting near miss safety events, healthcare organizations can
work on improving processes so that no one else makes the same error.

Precursor safety events occur when the healthcare error reaches the patient and
results in no harm or minimal detectable harm. Adverse events or serious safety
events occur when the error reaches the patient and results in moderate-to-severe
harm or even death. They are an undesired or unintended consequence of the care
provided, such as a significant decrease in blood pressure after a wrong dose of medi-
cation is given.

To differentiate a precursor safety event from a serious safety event, consider this
example. A nurse assesses Mr. Z and determines that he is a high fall risk. The nurse
puts fall prevention precautions in place, including placing the bed in its lowest posi-
tion, activating the bed alarm, and using floor mats to cushion the floor around the
bed. However, Mr. Z gets out of bed and falls before anyone can respond to his bed
alarm. If Mr. Z suffers no harm, the event is considered a precursor safety event. Like
near miss safety events, the nurse should report this precursor event and the care team
should investigate what could have been done differently to keep Mr. Z safe from falls.
After all, Mr. Z’s lack of injury was due to luck rather than healthcare system design.
On the other hand, if Mr. Z suffers a fall and fractures his hip, the injury is a serious
safety event. In addition to providing immediate patient care and reporting the serious
safety event, the nurse should participate in an in-depth analysis called a root cause
analysis (RCA). An RCA allows a healthcare team to determine the primary cause of
the safety event and put together an action plan to prevent it from happening again.
See Chapter 10 for further discussion of RCAs.

4 QUALITY AND SAFETY IN HIGH-RELIABILITY ORGANIZATIONS • 93

The healthcare team often becomes aware of errors at the point of care, where
nurses and other clinicians interact with patients. According to Cook and Woods
(1994), this is the “sharp end” of a triangle, where clinicians interface with patients.
Clinicians experience remorse and blame themselves when errors happen. However,
their work with patients is influenced by many factors and decisions made by indi-
viduals prior to an actual error event. These factors and decisions are the “blunt end”
of the triangle. For example, policies and procedures put in place to ensure consistent
healthcare processes may be inaccurate, difficult to interpret, or hard to access. Work
processes might be convoluted and patient handoffs can be inadequate. The environ-
ment may be cramped and noisy, making it difficult to concentrate. Technology can be
cumbersome or may fail completely. The culture of the hospital might hinder a nurse’s
ability to speak up about safety concerns. Groups and individuals may blame others
rather than taking responsibility for their actions. All of these “blunt end” factors can
contribute to an error at the “sharp end,” where the consequences of all healthcare
activities reach the patient.

James Reason (1997) proposed the Swiss cheese model to illustrate how errors
occur. The model suggests that every step in a process has the potential for error. The
holes in the Swiss cheese represent opportunities for a process to fail, and each slice is
a defensive layer to prevent an error in the process. An error may pass through a hole
in one layer but in the next layer, the hole is in a different spot and catches the error
before it reaches the patient. More layers of cheese and smaller holes allow more errors
to be stopped or caught. When the holes in the Swiss cheese line up, the defenses are
defeated and an error occurs.

For example, a nurse may be caring for a female patient who requires the insertion
of an indwelling urinary catheter. The intent is to place the catheter into the correct
patient using aseptic technique. A variety of protective layers are in place to prevent
errors as the nurse performs this procedure. The nurse is educated on the policy, pro-
cedure, and equipment. The nurse verifies the order and checks the patient’s identi-
fication using two patient identifiers. The nurse explains the procedure to the patient
and obtains an assistant to help with proper patient positioning. The nurse ensures
the environment is appropriate, with privacy and sufficient lighting. If one or more
of these protective layers are circumvented, an insertion error may occur, resulting in
patient harm.

CHARACTERISTICS OF HIGH-RELIABILITY
ORGANIZATIONS

Weick and Sutcliffe (2007) identified five key principles of high reliability organiza-
tions: preoccupation with failure, reluctance to simplify, sensitivity to operations,
commitment to resilience, and deference to expertise (Table 4.1). These characteristics,
when present, help an organization to achieve high reliability.

Preoccupation With Failure

Preoccupation with failure requires the nurse and other healthcare providers to be
aware that the risk of error is always present. An HRO acknowledges that failures can
occur and puts healthcare processes in place to diminish harm. An HRO proactively
identifies high-risk activities and analyzes all the potential error points in the process.
Conducting a failure modes and effect analysis (FMEA) is one way of accomplishing

94 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

this analysis. FMEA is a rigorous process in which a team of clinicians identify and
eliminate known and potential failures, errors, or problems before they actually occur
(Hughes, 2008). “Failure modes” refer to the ways in which something might fail and
cause potential or actual harm. “Effect analysis” examines the consequences of those
failures. Failures are prioritized according to the seriousness of the consequences,
how frequently they occur, and how easily they can be detected. The purpose of an
FMEA is to take actions to eliminate or reduce failures, starting with the highest prior-
ity ones.

For example, during an acute bleeding episode, a nurse may need to adminis-
ter multiple units of blood during a very short time period. This requires coopera-
tion among physicians, nurses, the blood bank staff, transportation staff, and many
others. A hospital might examine the process used for massive blood transfusion by
convening an interprofessional team. The team identifies each step in the process,
from ordering of the blood to administration and determines where failures might
occur. Through the FMEA, the hospital might learn that the greatest risk of error
occurs in small units with a limited number of nurses. As a result, they may create
a code transfusion team to bring additional resources to the bedside during acute
bleeding episodes.

Preoccupation with failure also requires that critical information is communi-
cated across time, across the healthcare team, and across sites of care. For example,
the day shift nurse communicates her concerns about the patient and what should
be monitored with the oncoming night shift nurse. Last, preoccupation with failure
requires the nurse to pay attention to near miss safety events and precursor safety
events as an early warning that something is wrong. This requires that nurses and
others report questionable or unsafe practices. Nurses need to recognize when an
error can or has occurred, feel confident in stopping unsafe practices, and assume
the responsibility for reporting errors or near misses. HROs then use those reports
to correct unsafe processes through rigorous process improvement activities.

TABLE 4.1 HIGH-RELIABILITY ORGANIZATION CHARACTERISTICS

CHARACTERISTIC ELEMENTS

Preoccupation with failure • Be alert to near-miss events
• Recognize weaknesses in healthcare systems early

Reluctance to simplify • Recognize the complexity of work
• Do not focus on superficial causes of failure

Sensitivity to operations • Acknowledge the complexity of healthcare processes
• Have situational awareness of the environment,

distractions, availability of resources and supplies
• Be aware of relationships

Resilience • Anticipate and mitigate failure
• Determine how to diminish risk of harm to patients
• Identify strategies to recover when an adverse event

occurs
Deference to expertise • Use teamwork that recognizes each member’s

knowledge, skill, and expertise
• Facilitate active participation from healthcare

professionals
• Be comfortable in sharing information
• De-emphasize hierarchy

Source: Adapted from Weick K. E., & Sutcliffe, K. M. (2007). Managing the unexpected: Resilient performance in an age
of uncertainty (2nd ed.). San Francisco, CA: Jossey-Bass.

4 QUALITY AND SAFETY IN HIGH-RELIABILITY ORGANIZATIONS • 95

Reluctance to Simplify

Reluctance to simplify drives an organization’s search to understand the cause of
errors. Staff members in HRO healthcare facilities focus on drilling down to determine
the true cause of error. They take nothing for granted and challenge the status quo
to make healthcare processes and structures safer. For example, a nurse may fail to
change a dressing. Upon questioning to determine why this event occurred, the easy
answer is “I forgot.” However, probing further for contributing factors to this failure
encourages the organization to find real, sustainable solutions. In the case of the dress-
ing change, the information may not have been shared at change of shift, or a prompt
in the electronic health record (EHR) may have been missing, or the necessary supplies
may not have been available at the time the nurse had planned to change the dressing.
An examination of each of these factors allows an HRO to determine ways to improve
the healthcare process.

Reluctance to simplify also addresses work arounds, a common phenomenon in
healthcare. Work arounds occur when nurses and other clinicians use shortcuts in an
effort to streamline care without realizing the potential impact on safety. For example,
healthcare organizations require dual (two person) verification for high-risk medica-
tions. Letty, a nurse in critical care, generally abides by this policy. However, she has
been administering a propofol infusion to her patient for several days and has begun
to adjust the dose without seeking an independent double check. Letty uses this work
around to save time. Unfortunately, it also increases risk to her patient. Leaders in
HROs identify and extinguish these types of workarounds.

Sensitivity to Operations

Sensitivity to operations creates an awareness of the many factors that influence the
care environment. Healthcare workflows are complex and factors such as fatigue, dis-
tractions, and workload can contribute to unsafe conditions. Sensitivity to operations
requires healthcare leaders to make rounds and talk to staff to look for weaknesses in
the care delivery system that allow errors to occur. Once weaknesses are identified,
leaders provide guidance and feedback and allocate resources to prevent harm. For
example, in an attempt to create an open-floor plan on a medical–surgical unit, the
automated medication dispensing system was placed in an alcove in the hallway. With
no barrier in place, the nurse was frequently interrupted by physicians, patients, visi-
tors, and other staff while obtaining medications from the dispensing system. Nurses
expressed concern about this process, which interfered with their ability to concen-
trate on the task at hand. Nursing leaders observed this when making rounds and
resolved the problem by creating a small medication room to house the automated
medication dispensing system and minimize distractions for the nurse while prepar-
ing medications.

Commitment to Resilience

Commitment to resilience addresses the need to talk about and learn from mistakes.
Rather than blaming others, clinicians in HRO healthcare settings discuss how the
error occurred and what can be done to prevent such an error in the future. Because
we are human, mistakes will happen. Resilience describes the ability to recover
when something bad happens. For an HRO, resilience is the ability to overcome

96 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

problems, learn from mistakes, and move forward. Transparency is paramount. An
HRO openly discusses errors and uses them to improve healthcare processes. Nurses
and other clinicians in an HRO are taught to perform quick situation assessments
when an error occurs, work as a team to contain or manage the error, and then take
steps to reduce the harm.

HROs ensure that clinicians are offered support when they are involved in a safety
event. When a nurse or other clinician makes an error that harms a patient, she or he
feels guilty. The term “second victim” has been coined to label the pain and anguish

experienced by the clinician (Wu, 2000). Programs have
been developed to assist clinicians to build resilience and
recover from these safety events. The forYOU program
(Scott, 2015) is an evidence-based second victim interven-
tion that provides immediate emotional and social sup-
port. Members of the forYOU team provide emotional
support using a three-tiered methodology. In tier one, local
support is provided by colleagues. In tier two, specially
trained peers provide support. In tier three, support is pro-
vided by a referral network of chaplains, social workers,
and employee assistance programs.

Last, simulation learning is a tool used in HROs to
practice responses to errors or safety events. Drills for
rapid responses, cardiopulmonary resuscitation, active
threats, and environmental disasters help nurses and other

clinicians to work as an interprofessional team and build
resilience for emergency situations (Figure 4.1).

Deference to Expertise

Deference to expertise acknowledges that collective expertise is better than any individ-
ual’s expertise. This deference allows an HRO to take advantage of the unique skills of
everyone involved. In an HRO, teams recognize that each member has knowledge and
skills unique to his or her profession and role. HROs minimize the authority gradient and
hierarchy so that everyone feels comfortable to speak up. Authority gradient refers to
positions within a group or profession, such as a direct care nurse and the nurse manager
or a medical resident and the attending physician. The term was defined first in avia-
tion when it was noted that pilots and copilots did not always communicate effectively in
stressful situations if there was a significant difference in their perceived authority. A num-
ber of unintentional aviation, aerospace, and industrial incidents have been attributed to
authority gradients. The concept of authority gradient was introduced to medicine in the
IOM’s(1999) report To Err Is Human. Hierarchy refers to perceived level of power across
groups, such as a housekeeper and a direct care nurse, or a direct care nurse and a physi-
cian. Healthcare has been and remains hierarchical. Physicians are viewed as the “captain
of the ship,” with nurses and other clinicians viewed as less powerful.

Regardless of authority gradient or hierarchy, deference to expertise specifies that
team members with the most expertise about the issue have the authority to make
decisions. For example, in an HRO, decisions about nursing practice are informed by
and driven by practicing nurses rather than by the chief nursing officer (CNO) or by
physicians. Ignoring a team member’s expertise can generate anger, indifference, or a
failure to respond, which create opportunities for error to occur. Open communication
with information flowing in all directions among all team members is essential for the
delivery of consistently safe care.

FIGURE 4.1 An interprofessional
team responds to a code in a
simulation center.

4 QUALITY AND SAFETY IN HIGH-RELIABILITY ORGANIZATIONS • 97

THE EFFECT OF HIGH RELIABILITY

A culture of reliability affects all aspects of an organization. HRO improves safety,
which was identified as one of the six elements of quality healthcare in the IOM’s
(2001) report Crossing the Quality Chasm. Patient safety is recognized as an important
element of an effective, efficient healthcare system. Safety has to do with lack of
harm and focuses on avoiding bad events. Safety makes it less likely that mistakes
and errors will happen. When care processes are performed as intended over long
periods of time, the result is no harm. For example, an interprofessional team may
focus on reducing harm to patients caused by catheter-associated urinary tract infec-
tions (CAUTIs). Using evidence from the literature and standards from professional
organizations, the team constructs a CAUTI bundle, a standard set of procedures to
be used consistently to prevent CAUTIs. If the procedures are consistently applied
by every clinician providing care to the patient, the likelihood of harming the patient
with a hospital-acquired CAUTIs usually drops exponentially. Functioning in a cul-
ture of reliability prevents harm and enhances safety.

Similarly, a culture of high reliability enhances quality. Quality has to do with
efficient, effective, and purposeful care that gets the job done at the right time for the
right cost. It focuses on doing things well and employs quality improvement tech-
niques so that the overall care continues to improve. CAUTI rates are widely measured
and reported as a quality measure for healthcare systems. At the individual level,
preventing CAUTI simproves quality for that patient.

In addition, a culture of reliability enhances the patient experience. The patient
experience is more than patient satisfaction. It is “the sum of all interaction, shaped by
an organization’s culture, that influences patient perceptions, across the continuum of
care” (The Beryl Institute, 2017). Most clinicians strive to provide patient-centered care
in a kind and compassionate manner. Yet all too often, patients receive mixed messages
and inconsistent information. This occurs because care is provided by humans, and
humans are fallible and variable in their approaches. However, in a culture of high reli-
ability, enhanced communication among staff results in more consistent communication
with patients. Clinicians are educated to be competent, compassionate, and consistent.
Patient satisfaction scores, one measure of the patient experience, tend to rise in such an
environment. Patients and their family members are unhappy when their care is unsafe
or of poor quality. Returning to the earlier CAUTI example, no patient wants to develop
a urinary tract infection, with the corresponding symptoms and required treatment.
Patients who have this experience often evaluate their overall care less positively when
they complete patient satisfaction surveys. They may also express their dissatisfaction
when talking with friends and families, thus eroding the reputation of the hospital.

Last, a culture of reliability also improves financial performance, which reflects
the income and the expenses of a healthcare organization. A culture of reliability helps
to increase income and decrease expense. Hospitals and ambulatory care settings are
increasingly being reimbursed based on safety, quality, and patient experience out-
comes. The Centers for Medicare and Medicaid Services (CMS) oversees three hospital-
based pay-for-performance programs that tie reimbursement to reliability: Value-Based
Purchasing (VBP) Program, Readmission Reduction Penalty Program, and Hospital-
Acquired Conditions (HAC) Reduction Program. In VBP, hospitals earn scores based
on achievement or improvement of their safety, quality, patient experience, and finan-
cial scores. VBP scores a hospital on five domains as follows:

• Patient- and caregiver-centered experience of care/care coordination (contribut-
ing 25% of the score)

• Clinical care outcomes (contributing 25% of the score)

98 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

• Efficiency and cost reductions (contributing 25% of the score)
• Safety (contributing 20% of the score)
• Clinical care processes (contributing 5% of the score)

The Readmission Reduction Penalty Program focuses on patients being readmitted
to hospitals for specific conditions, including acute myocardial infarction, coronary
artery bypass graft surgery, chronic obstructive pulmonary disease, heart failure,
pneumonia, and total hip and knee arthroplasty. The hospital’s actual readmission
rate is compared to the expected rate of readmissions given the patient’s comor-
bidities. Comorbidities are two or more coexisting medical conditions or disease
processes that are additional to an initial diagnosis. For example, a patient may be
admitted for a total knee arthroplasty. If the patient has diabetes and heart failure,
these coexisting conditions must be documented because they make patient care
more complex.

The HAC Reduction Program examines the hospital’s performance on coded data
derived from the documentation of physicians and advanced practice clinicians. The
coded data are then analyzed as part of the Agency for Healthcare Research and Quality
(AHRQ, 2013a) Patient Safety Indicators (PSI-90) and the Centers for Disease Control
and Prevention (CDC) National Healthcare Safety Network (NHSN) databases. In 2017,
6% of Medicare reimbursement to hospitals was tied to these three pay-for-performance
programs, representing billions of dollars. Hospitals with better than expected out-
comes received higher reimbursement for patients insured under Medicare, whereas
those with worse than expected outcomes received lower reimbursements.

Additionally, healthcare organizations may experience less waste and lower
cost when care is provided in a consistent manner. Returning to CAUTI preven-
tion as an example, an important first step in preventing the infection is to clearly
identify which patients truly require the insertion of an indwelling urinary cath-
eter. By providing evidence-based care and inserting indwelling urinary catheters
only when needed for care, the number of indwelling catheters can be reduced,
with a corresponding decrease in the CAUTI rate and the cost of urinary catheter
supplies. According to the Association for Professionals in Infection Control and
Epidemiology (2017), each urinary tract infection adds on average $5,904 to the cost
of the hospital stay. Simply put, hospitals and patients can save money by prevent-
ing CAUTIs.

LEARNING FROM OTHER INDUSTRIES

Commercial Aviation

Commercial aviation has worked diligently to change the culture in airplane cock-
pits to advance airline safety. Their work began after research conducted by the
National Aeronautics and Space Administration in the 1970s suggested that the
majority of commercial airplane crashes were caused by failure of communica-
tion among pilots and crew, not by mechanical failures. As a result, crew resource
management (CRM) training programs were developed and implemented. Teams
make fewer errors than individuals, especially when each team member knows
his or her own responsibilities along with those of other team members. The CRM
program is widely credited with the dramatic safety improvements in the airline
industry (Helmreich, Merritt, & Wilhelm, 1999) and has tremendous applicability
in healthcare.

4 QUALITY AND SAFETY IN HIGH-RELIABILITY ORGANIZATIONS • 99

Nuclear Power

Similarly, the nuclear power industry has worked for many years to improve safety.
The Institute of Nuclear Power Operations defines seven safety culture characteristics
that are adaptable to the healthcare environment as follows:

1. Leaders demonstrate commitment to safety in their decisions and behaviors.
2. Decisions that support or affect safety are systematic, rigorous, and thorough.
3. Trust and respect permeate the organization.
4. Opportunities to learn about ways to ensure safety are sought out and implemented.
5. Issues potentially impacting safety are promptly identified, fully evaluated, and

promptly addressed and corrected, commensurate with their significance.
6. A safety-conscious work environment is maintained where personnel feel free to

raise safety concerns without intimidation, harassment, discrimination, or fear of
retaliation.

7. The process of planning and controlling work activities is implemented so that
safety is maintained.

Science of Human Error: How Humans Function

Humans function primarily in three modes: skill-based performance, rule-based per-
formance, and knowledge-based performance. Each mode is described in the follow-
ing along with the errors that can occur when functioning in that mode.

When individuals are using skill-based performance, they are essentially on auto-
pilot. Skill-based performance is used for routine, familiar tasks that can be done with-
out thinking about them. For example, the drive to work or school may be so familiar that
the driver arrives without knowing how he or she got there. Nurses often function in this
mode because of the repetitive nature of some nursing tasks. Consider, for example, Jim,
a nurse completing his documentation in the EHR. Jim logs onto the EHR many times
each day. He does not need to think about his user identification or his password. He
is on auto-pilot. He pulls up his assigned patients in the EHR and begins to document.

In general, skill-based performance is accurate. But even though these repetitive
tasks may be simple, there is still a risk for error. Slips occur when, without intending to,
the individual does the wrong thing. Jim could pull up the wrong patient and document
care that was delivered to a different patient. Lapses occur when, without intending to,

CRITICAL THINKING 4.1 APPLYING NUCLEAR POWER
SAFETY CHARACTERISTICS TO HEALTHCARE

Review the seven nuclear power safety characteristics outlined in the chapter.

1. Which characteristics can be applied to healthcare?
2. How might a nurse leader demonstrate commitment to safety in decisions

and behaviors?
3. How have you seen nurses demonstrate trust and respect in your clinical

setting?
4. What experiences have you had at school to learn about ways to ensure

safety? What experience have you had in your clinical setting?
5. How might you raise safety concerns during your clinical rotations?

100 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

the individual fails to do what he meant to do. Jim could document on his patient but
forget to save or file his work before closing the record. Fumbles occur when, without
intending to, an individual mishandles a word or action. Jim may be documenting using
a hand-held device. If he drops the device, he has experienced a fumble.

Skill-based errors may be prevented by stopping and thinking before acting. Double
checking one’s own work helps to prevent these errors. This is why nurses learn to check,
recheck, and recheck again before administering medications. Determining that the right
drug in the right dose is being given by the right route, at the right time, and to the right
patient involves checking the medication label against the medication order or medica-
tion administration record three times. In addition, two unique patient identifies need
to be used prior to administering the medication. Healthcare facilities typically define
which two patient identifiers are to be used, most often full name and date of birth.
High-risk medications, such as insulin, require independent verification by another
nurse. The independence of this double check helps to prevent skill-based errors.

In rule-based performance, the clinician has learned a rule and applies it in appro-
priate situations. The delivery of healthcare is largely based on rules, often called proto-
cols. Rules may be learned in nursing school or through continuing education, clinical
experience, or life experiences. Errors may also occur when functioning in a rule-based
performance mode. Sometimes, clinicians use the wrong rule. They may have been
taught or somehow learned the wrong response for a situation. For example, Susan
learned many years ago in nursing school to treat patients with hypoglycemia if glu-
cose was 60 mg/dL or less. If Susan has not kept current with more recent diabetes
and hypoglycemia guidelines, she will fail to treat a patient with glucose of 70. The
solution to this type of error is to educate clinicians with the right rule.

A rule-based error may also occur if the clinician misapplies the rule. The nurse
may know the right response but select another response instead. For example, Susan
may know that a blood sugar of 68 should be treated with 15 g of glucose. However,
she may misapply the rule, and give 30 g of carbohydrates instead. This could over-
correct the low blood sugar, causing the blood sugar to spike and creating another
patient safety event. This can be prevented by pausing and thinking a second time.

Noncompliance can also cause a rule-based performance error. The clinician may
know the rule but choose not to follow it. For example, Susan knows that she should
recheck her patient’s glucose level 15 to 30 minutes after treating hypoglycemia. Susan’s
patient has a hypoglycemic event and she treats it appropriately. Susan sees that the patient
looks fine, is alert, and oriented. She assumes the patient will put on her call light if she
runs into any problems, so Susan decides not to recheck the blood sugar. Noncompliance
with rules can be prevented in several ways. First, Susan needs to understand the risks
involved in not following the rules. In addition, organizations need to reduce the burden
or difficulty of following the rules. For example, are there an adequate number of bedside
glucose monitors so that a glucose recheck is easy? Is staffing sufficient to allow time for
the glucose recheck? Susan also may need to be coached by her supervisor to make better
decisions. If this is a repeated behavior, Susan needs to be counseled.

In knowledge-based performance, a clinician is solving problems in a new and
unfamiliar situation. The clinician tries to figure out how to perform based on what they
already know. They may use trial and error or even guess at a solution. This is very dan-
gerous. Up to 60% of all knowledge-based decisions may be made in error. For example,
consider Cathy, an experienced nurse who has been working in critical care for 15 years.
When she arrives on her shift, her patient is receiving continuous renal replacement ther-
apy. Cathy has not previously managed this therapy and is not familiar with the supplies
and fluids used. Rather than proceeding independently, Cathy needs to stop and consult
an expert. The expert may be a colleague or another member of the healthcare team. Or
the expert may be a written resource, such as an evidence-based protocol.

4 QUALITY AND SAFETY IN HIGH-RELIABILITY ORGANIZATIONS • 101

The concepts of skill-, rule-, and knowledge-based performance are essential when
investigating errors. Clinicians involved in the error should focus on how they made the
decision they did. Did they develop a shortcut or work-around to save time? Did they fail
to do a double check of their own work? Did they proceed even though they were not
familiar with the procedure? Each type of error requires a different solution. The three per-
formance modes are critical to keep in mind when designing error prevention strategies.

THE ROLE OF LEADERSHIP IN CREATING A
HIGH-RELIABILITY ORGANIZATION

For the purposes of this chapter, leadership is defined as the governing body of an
organization, typically the board of directors or trustees, senior health system man-
agement, and nursing, physician, and other clinical leadership. To build an HRO,
all of these leaders must share the vision of eliminating harm to patients (Chassin &
Loeb, 2013). The governing body plays a critical role in setting goals and priorities for
healthcare organizations and in overseeing patient safety. Ganghi and Yates (2017)
identify the following eight questions board members should ask to ensure that the
healthcare organization is focused on safety:

• Is safety positioned as an uncompromising core value?
• Is there a comprehensive plan for improving patient and workforce safety and for

monitoring progress?
• Is transparency embraced for sharing adverse patient safety events and lessons

learned across the system?
• Do we have a healthy reporting environment and a fair and just culture?
• Do we expect respect for patients, coworkers, and physicians within the organization?
• Are patient stories heard regularly?
• Are quality and safety implications considered for every major organizational

decision?
• Does the board devote sufficient time to safety, quality, and the patient experience

of care?

Creating a Culture of Safety

Leadership is accountable for the provision of effective and efficient care while pro-
tecting the safety of patients, employees, and visitors. Competent leaders understand
that every step of the care process has the potential for failure simply because humans

What is the role of the board of directors in our journey toward high reliability?
We begin with the philosophy that “good isn’t good enough.” We need to be
sensitive to our systems and processes to identify where things may not work or
can be improved upon. And we must build a culture of open communication and
reporting by all, for the good of all, to inspire and achieve greater results.

Joseph DePaulo
Board Member, Edward-Elmhurst Health; and Chair, Edward Hospital Quality

Committee of the Board

REAL-WORLD INTERVIEW

102 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

make mistakes. TJC’s Sentinel Event Database suggests that leadership’s failure to cre-
ate an effective safety culture is a contributing factor for many types of adverse events
(TJC, 2017, February 17). Understanding and shaping an organization’s culture is essential
for enhancing safety.

A culture of safety is what an organization is and does in the pursuit of safety (TJC,
2017). Leaders in HRO healthcare facilities realize their role in creating a culture of safety.
As such, leaders need to show their commitment to safety and eliminate fear of reporting.
Leaders must make their commitment to safety clear. This is accomplished in a variety of
ways: telling safety stories at each meeting; expecting, encouraging, and rewarding the
reporting of safety events; and expecting and supporting staff to speak up for safety. The
focus of a safety story can be on an event of harm, an explanation of why safety is impor-
tant, a review of an error prevention tool, a thank you for being committed to patient or
employee safety, or an example of using a safety tool at home or at work. Many hospitals
use these techniques to keep safety at the top of everyone’s mind.

Leaders in HRO organizations know they must eliminate the fear of reporting in
order to encourage and reward the reporting of safety events. This may be accomplished
by thanking staff for reporting errors, mistakes, events, and near misses. The Good Catch
award is one way to recognize staff who report near misses or close calls (Figure 4.2).
Many hospitals across the nation have implemented the Good Catch award program.
Edward Hospital in Naperville, Illinois, implemented the Good Catch award in 2008.
Each month, risk managers identify safety events that have been identified by staff and
have not reached the patient to cause harm. They summarize the top safety events and
ask members of the senior leadership team to vote on the most important event. The
person or team responsible for submitting the top safety event is recognized at a man-
agement team meeting and receives a certificate, a lapel pin, and a Good Catch traveling
trophy, which rotates monthly. The Good Catch program recognizes those who speak up
about near miss safety events, and fosters a culture of transparency and safety.

During handoff report from the emergency department, Colleen Erhardt, RN,
learned that her patient had become increasingly confused. Upon arrival to the
floor, her patient remained disoriented, had garbled speech, and was lethargic.
No family was present and the patient’s spouse could not be reached. Physician’s
orders included a neurology consult, stat head CT scan, and NPO status. While the
patient was receiving his CT scan, Colleen reviewed the patient’s morning lab work
and noted his blood sugar was 70 mg/dL. Realizing there had not been a repeat
blood sugar obtained since that time, Colleen proceeded to the radiology depart-
ment to check the patient’s blood sugar and found it had decreased to 31 mg/dL.
Colleen administered 50 mL of D50. The patient immediately responded and was
able to answer all orientation questions appropriately. The neurologist was notified
of the blood sugar and CT results, which revealed no acute neurological problem.
The neurologist noted the source of the patient’s confusion appeared to be hypogly-
cemia and after this was resolved, the patient returned to normal.

1. What type of error is a Good Catch?
2. What factors allowed Colleen to make this Good Catch?
3. What are the typical signs and symptoms of hypoglycemia?
4. Why might this patient have experienced this episode of hypoglycemia?
5. Why is it important to identify and discuss Good Catches?

CASE STUDY 4.1

4 QUALITY AND SAFETY IN HIGH-RELIABILITY ORGANIZATIONS • 103

HRO leaders support investigations
into how errors occur. This encourages
reporting and learning. HRO leaders
make errors visible in a way that has
meaning to the audience. For example,
hospitals tend to report injuries as percent-
ages, rates, or raw numbers. However,
putting a face to that number is essential
for understanding the impact of the
error. For example, consider this commu-
nication, which demonstrates transparency
and paints a vivid picture of the event:
“We had one fall with injury reported this
week. The patient was a grandmother who
required surgery to repair her fractured
hip and experienced a prolonged separa-
tion from her family because of her stay in
a skilled nursing facility.”

Correcting System Problems

Consistent with sensitivity toward opera-
tions, leaders must identify and correct sys-
tem problems. HRO leaders are always on
the lookout for system problems and work diligently to fix those problems. A helpful tool
to accomplish this is a daily safety huddle. This brief huddle includes senior and opera-
tional leaders who meet at the start of each day to discuss safety concerns and resolve
problems. Operational leaders prepare for the daily safety huddle by reviewing the past
24 hours and anticipating the next 24 hours. They summarize safety issues that have
already occurred and identify if those safety issues impact other departments. They dis-
cuss any barriers to providing safe care, such as inadequate supplies, staffing, or technol-
ogy. They describe any high-risk or nonroutine situations, such as two patients with the
same first and last names on the same unit. At the daily safety huddle, issues critical to the
safety of patients or staff can be addressed quickly and efficiently. Appropriate experts are
mobilized and empowered to solve the problem. For example, safety huddles may reveal
an increase in work place injuries inflicted by patients. This information may be used to
launch a system-wide task force designed to decrease violence in the workplace, including
early identification of potential problems, environmental modifications, and employee
training. Workplace injuries will begin to decrease if the interventions are effective.

FIGURE 4.2 Colleen Erhardt, RN (right),
receiving the Good Catch Award with her
manager, Deb Kocsis, RN.

“The single best thing we’ve implemented here as part of our ‘Road to Zero
Harm’ is the daily Safety Huddle. While it only lasts 10 to 15 minutes, we all
attend or call in to hear 49 operational leaders report on the safety issues in their
areas. The Safety Huddle allows us to quickly identify and act on safety trends.
It’s helping to make our care safer.”

Bill Kottmann
President and CEO, Edward Hospital

REAL-WORLD INTERVIEW

104 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

Building and Reinforcing Accountability

HRO leaders are also responsible for building and reinforcing accountability. They
reinforce sound safety habits, console those who make honest mistakes, and counsel
those who make risky choices. To build a culture of accountability, leaders must set
clear expectations, educate and build skills within the staff, and build and reinforce
accountability. The behavioral expectations should be consistent with the organiza-
tion’s mission, vision, goals, and standards for performance. Edward Hospital uses
the phrase “Road to Zero Harm” to connote their journey toward high reliability.
Individuals at all levels of the organization must be educated on these expectations.
In addition, leaders need to create a system that allows nurses and other staff members
to convert all their behaviors into safe work habits.

Individuals experience three sources of accountability: vertical, horizontal, and
intrinsic. Vertical accountability is applied by leaders, that is, the sense that managers
are watching. Peers account for horizontal accountability, the sense of teamwork and the
desire to function as effectively as others. Intrinsic accountability exists within the indi-
vidual. All three types of accountability are important in creating a culture of safety and
accountability. Leaders need to expect accountability and build the intrinsic motivation of
the individual to meet performance expectations. HRO leaders take every opportunity to
build and reinforce accountability by making regular rounds and creating a just culture.

Leaders who visit and make rounds to clinical practice areas are essential for build-
ing a culture of high reliability. “Management by walking around” allows leaders to see
firsthand the conditions that exist at the front line, where care is being delivered. Making
rounds demonstrate leadership’s commitment to safety and allow leaders to talk with
staff about safety concerns for themselves and their patients. It also provides an oppor-
tunity for leaders to provide quick feedback and reinforcement to staff. The science of
human performance suggests that providing both positive and constructive feedback is
needed to decrease human errors, and that the overwhelming majority of feedback should
be positive. Instant feedback helps to reinforce positive behaviors and should be immedi-
ate and based on facts. A verbal thank you for practicing safely is very effective in rein-
forcing safe behaviors. During rounds, leaders may observe unsafe behaviors and should
immediately correct the behavior and offer a practice tip to extinguish the unsafe behavior.

For example, nurses and clinicians in many hospitals and healthcare settings are
inconsistent in performing hand hygiene before and after patient contact (see Figure 4.3).
Edward Hospital is no exception. As a result, leaders decided to focus on hand hygiene
during rounds. To prepare leaders, a rounding tool was created by Mary Anderson, an
infection preventionist at Edward Hospital. The rounding tool allowed leaders to relate
hand hygiene to the core value of safety. Clinicians were then asked how they perform
hand hygiene and expectations were clarified if necessary. Clinicians were asked what
barriers exist for performing hand hygiene and how hand hygiene can be better met in
the future. Last, clinicians were asked to commit to performing hand hygiene and help-
ing others to do the same. This effective rounding tool provided actionable feedback to
leaders (for more information, go to www.eehealth.org). For example, leaders received
input on the need for structural modifications, and they are working to increase the num-
ber of sinks and hand gel stations.

Creating a Fair and Just Culture

Leaders are also responsible for creating a fair and just culture. A fair and just culture min-
imizes blame and punishment and creates an environment that encourages individuals
to report errors so that the system problems can be corrected. Traditionally, healthcare’s

4 QUALITY AND SAFETY IN HIGH-RELIABILITY ORGANIZATIONS • 105

culture has held individuals accountable for all errors that occur with patients under their
care. This punitive approach toward errors views those who make errors as “bad apples”
(IOM, 1999). This approach has served as a disincentive to reporting errors and mistakes.
After all, who would report an error if it meant they would get in trouble? As a result,
organizations missed opportunities to uncover and correct problems that impacted
performance and outcomes. The pendulum then swung to the opposite extreme, to a
nonpunitive culture. This was interpreted by some to mean the individual was always
blameless when an error occurred, which allowed intentional disregard for work rules.
Most recently, the concept of a just culture has been embraced within healthcare.

James Reason (1997) wrote that a just culture creates an atmosphere of trust, encour-
aging and rewarding people for providing essential safety-related information. A just
culture also clearly identifies what constitutes acceptable and unacceptable behavior.
Marx David (2001) wrote that individual practitioners should not be held accountable
for system failings over which they have no control. He held that discipline should be
tied to the behavior of individuals and the potential risks of their behavior rather than
only to the actual outcome of their actions. A just culture recognizes that many errors
represent predictable interactions between human operators and the systems in which
they work. In a 2010 position paper, the American Nurses Association (2010) endorsed
the just culture model, noting its wide use in the aviation industry.

Ultimately, the just culture model is about creating a learning culture that is open
and fair; managing behavioral choices; and designing safe healthcare systems. The
model acknowledges that humans make mistakes and because of this no system can
be designed to produce perfect results. A just culture views errors as opportunities

FIGURE 4.3 Clean Hands Count for Healthcare Providers.
Source: Centers for Disease Control and Prevention. Retrieved from http://cdc.gov/handhygiene

106 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

to improve the understanding of both healthcare system risk and individual behav-
ioral risk. It changes staff expectations and behaviors so that everyone looks for
risks in the environment; reports errors; helps to design safe healthcare systems;
and makes safe choices, such as following procedures, policies, and protocols.

The just culture model requires leadership competencies that appropriately hold
individuals accountable for their behaviors and investigates the behavior that led to the
error. James Reason (1997) developed a Performance Management Decision Guide that
is used across the world to guide management decisions when human error occurs. It
starts with a deliberate act test. If the individual acted with malicious intent, disciplinary
action and a report to a professional group, regulatory body, and/or law enforcement
is warranted. If there is confirmed ill health and the individual was unaware, a leave of
absence and physician referral are appropriate. If substance abuse is suspected, testing
and disciplinary action are warranted. If the individual chose to take an unacceptable
risk based on policies, procedures, and protocols commonly used within the organiza-
tion, disciplinary action may be warranted. However, if the individual adhered to gen-
erally accepted performance expectations and simply made an unintended error, the
individual needs to be consoled and coached. In every case, leadership is also respon-
sible for correcting all safety problems that contributed to the error.

Fostering a Learning Environment

The learning organization was first described by Peter Senge (1990) as an organization
where people continuously learn and enhance their capabilities to create. An HRO
cannot exist in the absence of learning. A learning organization views each failure as
an opportunity to learn from mistakes. An HRO readily admits its weaknesses and
commits to learning from its mistakes (Hughes, 2008). Key tenets of improving patient
safety at the organizational level include taking a systems approach to safety and
improving the culture of safety. Healthcare systems that embody this approach are
considered learning organizations. Leaders in these organizations support learning
and create a supportive learning environment. They put specific processes in place to
facilitate learning and encourage creativity among employees. Such a learning envi-
ronment requires a level of transparency related to safety, so that everyone is aware
of opportunities for improvement. Reporting errors and near miss safety events can
assist in understanding a problem rather than hiding that a problem exists.

Enhancing Process Improvements

An HRO has a strong commitment to healthcare process improvement. Becoming an
HRO requires a systematic look at the complexity of the healthcare process, identifica-
tion of the root causes of failures in the healthcare process, implementation of solutions,
measuring and monitoring outcomes from the implemented solutions, and then build-
ing ways to sustain the improvement. In some cases, an entirely new process may be
required to enhance safety. Increasingly, patients and their families are being engaged
to assist in healthcare process improvements. The use of systematic process improve-
ment methodologies and tools such as Six Sigma and Lean are discussed in Chapter 13.

Identifying and Reporting Events

In an HRO, all healthcare providers are responsible for reporting safety events, includ-
ing near misses, adverse events, and sentinel events. This type of reporting has its limi-
tations, as it depends on both the recognition of the safety event and the completion of

4 QUALITY AND SAFETY IN HIGH-RELIABILITY ORGANIZATIONS • 107

a safety event report. When using voluntary reporting and error tracking, only around
10% to 20% of all errors are reported in healthcare organizations (Classen, Lloyd,
Provost, Griffin, & Resar, 2008). Hospitals need a more effective way to identify events
that cause harm to patients in order to select and test changes to reduce harm.

In an HRO, a multifaceted reporting approach is needed that is comprehensive
and provides accurate measurements of errors and near misses. The Institute for
Healthcare Improvement (IHI) Global Trigger Tool (GTT; IHI, 2017c) helps health-
care organizations get a clearer understanding of the safety of care by measuring
risk and harm at the hospital level. The GTT uses specific patient care triggers as
indicators that an adverse event (AE) may have occurred. Using GGT to identify
AEs is an effective method for measuring the overall level of harm from patient care
in a healthcare organization. The GTT provides an easy-to-use method for accu-
rately identifying AEs (harm) and measuring the rate of AEs over time. Tracking
AEs over time is a useful way to tell if changes being made are improving the safety
of the patient care processes.

For example, transfer to a higher level of care is one of the Global Triggers. A patient is
transferred to the ICU from a medical–surgical unit due to a rapid drop in blood pressure
and decreased level of consciousness. This would cause activation of the trigger and a
review of the patient’s EHR to determine what happened to the patient, when it happened,
and if it could have been avoided. There are more than 50 triggers that are consolidated
into categories on the GTT related to the provision of surgical, ICU, perinatal, medication,
and emergency department care. The categories and triggers can be viewed at the IHI
website (www.ihi.org/resources/Pages/Tools/IHIGlobalTriggerToolforMeasuringAEs.
aspx). In an HRO, investigation results and the GTT results are shared with healthcare
providers and process improvement changes are put into protocols, policies, and proce-
dures to reduce the chance of future safety problems occurring.

Deploying Technology

In an HRO, health technologies help facilitate and sustain quality improvement
efforts to improve patient safety. For example, the use of IV pumps with built in
limits for high and low medication doses helps to reduce medication errors. Elaine
is caring for a patient with a pulmonary emboli. She reviews the medication orders
to administer 80 units of heparin per kilogram by IV bolus, followed by 18 units per
kilogram as an hourly infusion. Elaine knows her patient weighs 150 pounds, or 68
kg. She correctly calculates and administers the initial dose of 5,540 units. Elaine
calculates the continuous infusion rate at 1,224 units per hour. When programming
the pump, however, her finger slips and she enters 12,244. Because that dose is
beyond the normal range for heparin, the pump does not administer the drug, and
Elaine receives an error message. She quickly identifies and corrects the program-
ming. A double check from a peer for this high-risk medication would also catch
this programming error before it reaches the patient.

All too often, however, hospital leaders apply technology to faulty healthcare pro-
cesses and hope to prevent errors with technology. Technology can only help improve
healthcare processes when applied appropriately. A focus on a safe and efficient health-
care process design using technology to support and sustain any improvement is critical.

Committed leaders are needed to implement system changes that are essential
for becoming an HRO. However, leadership is not sufficient. Every individual within
an organization needs to be committed to high reliability. The next section addresses
the individual responsibilities for nurses and other members of the interprofessional
healthcare team on a journey toward high reliability.

108 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

INDIVIDUAL RESPONSIBILITIES: SAFETY BEHAVIORS
FOR NURSES

While many contributing factors lead to errors, an actual error occurs when the clini-
cian interacts with the patient, at the “sharp end” of care. The nurse is often the last
line of defense against healthcare errors. As such, the nurse must be cognizant of both
internal behaviors to enhance safety and communication techniques that can be help-
ful in preventing errors and patient harm.

Internal Behaviors to Enhance Safety and High Reliability

Nurses and other members of the interprofessional healthcare team must always strive to
focus their attention and to think before they act. This is effective in preventing many task-
based errors, especially in stressful, noisy, and pressured situations. A tool used to focus
and think in these situations is Pause-Act-Review (PAR). Nurses and other clinicians are
asked to pause for 1 or 2 seconds to focus their attention on the task; act by concentrating
and performing the task; and review their actions to check for the desired result. This self-
checking takes only a few seconds but greatly reduces the probability of making an error.

For example, Karly, a nurse on the telemetry unit, uses the PAR technique when
pulling medications from the automated medication dispensing system (Figure 4.4). She

pauses, acts, and reviews her action. The automated
medication dispensing system is located in the supply
room; the area gets considerable traffic and can become
noisy. Karly recognizes that noise and congestion can
increase the risk of errors. She takes her concern to the
Practice Council, and a decision is made to post a sign
by the automated medication dispensing system. The
sign serves two purposes. It reminds other staff to be
quiet and avoid interrupting the nurse who is prepar-
ing medications, and it reminds the nurse to use PAR.

Another internal behavior helpful in enhancing
safety is maintaining a questioning attitude when
providing patient care. The nurse must carefully
consider the patient care situation and ask questions
of herself. Is this what I expected to see? Does this fit
with what I know? Does this make sense to me? If a
question or concern remains, the nurse confirms by
checking with independent, expert sources, either
competent people or written materials that can help
in resolving the question.

As an example of a questioning attitude, Chris is
caring for a 3-month-old with a history of supraven-
tricular tachycardia who is admitted to the pediatric
ICU with a cough and congestion. Chris reviews the
medication orders and finds orders for propranolol
20 mg TID. As an experienced pediatric nurse, Chris
realizes that this dose is high. He knows pediatric
doses are weight-based and consults a drug refer-
ence book (an external expert) to determine the
appropriate dose. Chris also talks with the mother

FIGURE 4.4 Karly Blaschak, RN, focuses
on retrieving medications from an auto-
mated medication dispensing system.

4 QUALITY AND SAFETY IN HIGH-RELIABILITY ORGANIZATIONS • 109

(an expert in her child’s care) and finds that the infant was taking 2 mg of propranolol
TID at home. Chris questioned what he saw and investigated appropriately. He then
spoke to the physician, who changed the medication order and thanked Chris for his
diligence.

Communication Techniques

In the fast-paced healthcare arena, clear communication is essential, both within nurs-
ing and with other members of the interprofessional team. Communication ensures
that messages are heard correctly and accurately and prevents incorrect assumptions
and misunderstandings that could lead to wrong decisions. One of the National Patient
Safety Goals (NPSGs) is to improve the effectiveness of communication among care-
givers (TJC, 2016). TeamSTEPPS® (AHRQ, 2013b) provides a variety of tools that can
be helpful in improving communication, including callout and closed loop (or three-
way) communication. Callout is a tool used to communicate important information.
It informs all team members simultaneously during an emergency and helps team
members anticipate next steps. For example, during a code, the nurse uses a callout to
report “I’ve administered 1 mg epinephrine IV.”

Closed-loop communication ensures that the message received is the same as the
message sent. The sender initiates communication with a receiver by providing an
order, request, or information. The receiver acknowledges the communication with a
repeat-back of the order, request, or information. The sender then confirms the accu-
racy of the acknowledgment by saying “that’s correct.” If communication is not clear,
the nurse must clear up the confusion. “Let me ask a clarifying question” is a helpful
and nonthreatening phrase to use when attempting to clarify communication. As an
example, Pam is a nurse on a medical–surgical unit. When she receives a telephone
order from a physician, she enters it into the EHR and reads it back to the physician.
Pam waits for the physician to verify the order before terminating the conversation.
Pam also uses closed-loop communication when communicating with or delegating to
a patient care tech (PCT).

Communication also includes the transfer of information during transitions of
care, for example, during shift changes, transfer to another unit, or discharge from
the hospital. These communication handoffs provide an opportunity to ask questions,
clarify information, and confirm understanding. The tools I PASS the BATON and
SBAR can be used effectively in handoffs. The I PASS the BATON acronym for remem-
bering the key components of the handoff is presented in Box 4.2.

The acronym, SBAR, stands for Situation, Background, Assessment, and Recom-
mendation. It was originally adapted by Kaiser Permanente from a U.S. Navy tool
to enhance collaboration between nurses and physicians (IHI, 2017b). In the struc-
tured SBAR communication, Situation refers to a concise statement of the immediate
problem. Background includes brief and pertinent information related to the situation.
Assessment refers to analysis and consideration of action options. Recommendation
addresses the actions requested.

Jean uses SBAR as a nurse in labor and delivery. When caring for Mrs. Jones, she
calls the obstetrician to report, “Here’s the situation. I’m concerned about the decelera-
tions that Mrs. Jones is experiencing. Mrs. Jones is 34 years old, gravida 2, para 1. My
assessment finds baseline fetal heart tones are 120 with minimal variability and repeti-
tive late decelerations. I’ve initiated all intrauterine resuscitation measures without
improvement. I need you to come assess Mrs. Jones as quickly as possible. When can
I expect to see you?”

110 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

Initially, it appears that speaking up for safety is an easy behavior. After all, health-
care providers come into healthcare to do the right thing, help patients, and cause no
harm. However, speaking up for safety requires a change in culture. Leadership must
clearly communicate that everyone has the authority to stop for a safety concern at any
time. Nurses are expected to voice their concern and “stop the line” if they sense or dis-
cover a safety issue. The acronym CUS may be used, representing “I am Concerned”;
“I am Uncomfortable”; and “This is a Safety Issue.” A phrase like “I have a safety con-
cern” is useful to help staff feel comfortable with speaking up.

Consider this example of a culture where nurses feel empowered to speak up for
safety, regardless of authority gradient. Mary Ann was caring for an infant in the NICU.
At the request of the infant’s parents, the hospital’s CEO, COO, and CNO arrived in the
private NICU room. Mary Ann calmly and professionally asked, “Did you scrub in?” All
three retreated to the sink, scrubbed in, and thanked Mary Ann for speaking up. In fact,
Mary Ann received recognition for her actions at a management team meeting. Mary
Ann’s action ensured safety for a vulnerable infant. The story of the positive response of
the CEO, COO, and CNO spread widely throughout the hospital, helping to promulgate
the understanding that everyone is rewarded for speaking up for safety.

The Interprofessional Team

The delivery of healthcare requires strong and supportive healthcare teams. Team mem-
bers monitor team function, share the workload, and support each other. TeamSTEPPS
(AHRQ, 2013) provides team strategies and tools to enhance performance and patient
safety. CRM, described earlier in this chapter, has been adopted from aviation into
healthcare to promote and reinforce team behaviors such as cooperation, coordination,
and sharing regardless of formal position. It has been used to improve patient care in
obstetrics, the operating room, emergency department, and other settings (Kreiser, 2012).

Providing feedback to team members is important for fostering high performance.
HROs foster a culture where nurses and other staff members are expected to provide
and are comfortable providing both positive and constructive feedback to team members.
Positive feedback is essential for reinforcing safe behavior. Clinicians perform many safe

I—Introduction—Introduce self and role
P—Patient—Name, identifiers, and basic demographic information
A—Assessment—Present chief complaint, vital signs, and diagnoses
S—Situation—Current status, including code status, recent changes, and response to
therapy
S—Safety Concerns—Critical lab values, allergies, alerts such as high fall risk and isolation
B—Background—Comorbidities, previous issues, current medications, family history
A—Actions—Actions taken or provided with rationale
T—Timing—Level of urgency and prioritization
O—Ownership—Identify who is responsible, including patient and family members
N—Next—Plan of care, anticipated changes, contingency plan

BOX 4.2 I PASS THE BATON

Source: Adapted from Agency for Healthcare Research and Quality (AHRQ). (2013). TeamSTEPPS® pocket guide. Retrieved from
https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/essentials/
pocketguide.pdf

4 QUALITY AND SAFETY IN HIGH-RELIABILITY ORGANIZATIONS • 111

actions every day and should be recog-
nized for that. Constructive feedback
is needed to discourage and change
unsafe behaviors. People tend to avoid
constructive feedback because they are
uncomfortable providing it. However,
as in the speaking up example earlier in
this chapter, Mary Ann reminded oth-
ers to wash their hands before enter-
ing the patient’s room. This simple
reminder is often all that is needed to
correct behavior. Constructive feedback
should always be met with a thank you
and a change in behavior.

Cross-monitoring is tool to assist
in error reduction during team func-
tioning. Cross-monitoring allows team
members to take advantage of working
together and monitor unusual situa-
tions or hazards, identify safety slips
or lapses, and provide impromptu consultation and feedback. For example, TJC (2017,
March 1) has set an NPSG to improve the accuracy of patient identification. Because of
the negative outcomes that could occur if incorrect blood were administered to a patient,
the NPSG requires a two-person identification process if automated identification
technology is not available. The two-person process with a peer is an essential safety step
and reinforces teamwork when providing care. Some hospitals adopt a phrase such as
“I’ve got your back” to connote a supportive team environment (Figure 4.5). In this way,
staff support each other and feel comfortable asking each other for help.

Providing mutual support to team members builds a strong team and helps mem-
bers avoid work overload situations. Mutual support is the ability to anticipate team
members’ needs and provide assistance as needed through accurate knowledge about
their workloads and responsibilities. By providing mutual support and feedback to
a team member, team function is enhanced. Feedback should be timely, respectful,
specific, considerate, and directed toward quality improvement. Team members are
expected to advocate for the patient, particularly when a team member’s view doesn’t
coincide with that of the main decision maker on the team. If conflict erupts on the
team, the DESC tool can be used to manage and resolve the conflict: First, describe the
specific situation or behavior you are concerned about and provide concrete data about
it. Next, express how the situation makes you feel and what your concerns are. Third,
suggest alternative actions and seek agreement. Last, state possible consequences in
terms of impact on established team goals and strive for team consensus. Try using this
tool the next time you have a safety concern.

ASSESSING THE CULTURE OF A HIGH-RELIABILITY
ORGANIZATION

Organizational culture is the shared values and beliefs of individuals in a group or organi-
zation. Schein (2004) describes organizational culture at three levels: observable artifacts,
values, and basic underlying assumptions. Observable artifacts are visible manifestations
of values and may include signage, décor, dress code, traffic flow, medical equipment,

FIGURE 4.5 Three Edward Hospital
emergency department nurses have each
other’s backs.

112 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

and visible interactions. Values are explicitly stated norms and social principles and are
manifestations of an organization’s assumptions. Basic underlying assumptions are the
shared beliefs and expectations that influence perceptions, thoughts, and feelings about
an organization. They are the core of an organization’s culture. These assumptions define
the culture of the organization, but because they are invisible, they may not be recog-
nized. At times, the assumptions of an organization are unclear and self-contradictory,
especially when an organizational merger or acquisition has occurred.

Essentially, culture is how we act when no one is looking. Take for example,
Elizabeth, a patient care technician caring for a patient in isolation. Elizabeth entered
the patient’s room without donning appropriate personal protective equipment. She
deviated from policy and may have put herself, her family, patients, staff, and every-
one she encountered at risk of infection. When asked about her behavior, she admit-
ted that she knew the patient was in isolation and that she should put on a gown and
gloves. Elizabeth stated, however, that she did not think anyone was watching. This
illustrates an employee who has not yet internalized a culture of safety.

On the other hand, consider Tom, a housekeeper who informed his supervisor that
he found a piece of metal that came off the door handle in a restroom on the Adolescent
Behavioral Health Unit. Tom was concerned that there were sharp edges and that some-
one could get hurt. The supervisor asked facilities to fix the handle as quickly as possi-
ble. The facilities manager noted that two screws were missing and asked Tom if he had
found them. When Tom said no, the manager of the Adolescent Unit was notified of the
situation and staff members searched each patient’s room. After a long and exhaustive
search, the missing screws were located in a patient’s orthodontic retainer case. Because
of Tom’s attention to detail and willingness to speak up, the patient was kept safe from
harming himself. This scenario exemplifies an employee who is living a culture of safety.

Many organizations use a culture of safety survey tool to capture the perspectives
of healthcare providers. Two commonly used tools are the survey on patient safety
culture (AHRQ, 2017) and the safety attitudes questionnaire (Sexton et al., 2006).
Organizations may also choose to assess their stage of organizational maturity toward
becoming an HRO using a model proposed by Chassin and Loeb (2013).

To support a culture of patient safety and quality improvement, AHRQ spon-
sored the development of separate patient safety culture surveys for hospitals, nurs-
ing homes, medical offices, community pharmacies, and ambulatory surgery centers.
Each survey measures various dimensions of the safety culture. For example, the
hospital survey measures teamwork within units; supervisor/manager expectations
and actions promoting patient safety; organizational learning; management support
for patient safety; overall perceptions of patient safety; feedback and communication
about error; communication openness; frequency of event reporting; teamwork across
units; staffing; handoffs and transitions; nonpunitive response to errors; and number
of events reported; and asks the participant to assign a patient safety grade to the orga-
nization. The patient safety culture surveys are available in English and Spanish and
are publicly available at no cost on the AHRQ website (https://www.ahrq.gov/sops/
quality-patient-safety/patientsafetyculture/index.html).

AHRQ has established comparative databases for patient safety culture survey
data from organizations that administer the surveys. The databases allow healthcare
organizations to compare their patient safety culture survey results to similar sites in
support of patient safety culture improvement. AHRQ provides an action-planning
tool to assist an organization in analyzing and improving its patient safety culture.
Survey results are used by organizations to:

• Raise staff awareness about patient safety
• Diagnose and assess the current status of the patient safety culture

4 QUALITY AND SAFETY IN HIGH-RELIABILITY ORGANIZATIONS • 113

• Identify strengths and areas of opportunity for patient safety culture improvement
• Examine trends in patient safety culture changes over time
• Evaluate the cultural impact of patient safety initiatives and interventions
• Conduct internal and external evaluations of the culture of safety

The safety attitudes questionnaire was developed with funding from the Robert
Wood Johnson Foundation and AHRQ (med.uth.edu/chqs/surveys/safety-attitudes-
and-safety-climate-questionnaire/). The 36-item survey is designed to obtain frontline
staff perspectives about specific patient care areas. The key factors that are measured
on the survey are teamwork climate, safety climate, perceptions of management, job
satisfaction, working conditions, and stress recognition. The survey is known to be
accurate in measuring these factors and is used by healthcare organizations to com-
pare themselves to other organizations, identify interventions needed to improve
safety attitudes, and measure the effectiveness of the interventions.

Chassin and Loeb (2013) developed a grid to allow healthcare organizations to assess
their stage of organizational maturity toward becoming an HRO: beginning, develop-
ing, advancing, and approaching. Chassin and Loeb identified performance based on
position in the organization (board member, CEO/management, physicians); initia-
tives (quality strategy, quality measures, information technology); safety culture (trust,
accountability, identifying unsafe conditions, strengthening systems, and assessment);
and robust process improvement (methods, training, and spread). Their grid may be
used by leaders to assess their journey toward becoming an HRO.

IDENTIFYING AND OVERCOMING BARRIERS TO
HIGH RELIABILITY

Achieving high reliability in an organization is an ongoing journey, with many barri-
ers along the way. The culture, history, and traditions of a healthcare organization can
pose a barrier to becoming an HRO. Workplace intimidation and disruptive behaviors
can oppose the creation of an HRO. Blending various professional healthcare subcul-
tures into a common professional culture creates challenges for leaders. In addition,
the lack of robust health technology and information systems can undermine the abil-
ity to achieve high reliability and safety. Regardless of the challenges, organizations
can overcome each barrier.

Culture, History, and Traditions

The overall culture of an organization is a reflection of past learning experiences.
Revising the cultural patterns of basic assumptions and beliefs is difficult, time con-
suming, and anxiety provoking. If a past experience with reporting an error resulted
in punishment, it may deter future reporting of errors. The fear of punishment can be a
significant barrier to error reporting. Changing the culture requires a significant lead-
ership commitment to focus on healthcare processes and systems that lead to errors
rather than on individual blame. Considerable effort is required to change a long-
standing tradition of blame and punishment.

The history and traditions of a healthcare organization set the stage for becoming
an HRO. Some healthcare organizations assume that high reliability is not achievable in
healthcare. The amount of change needed to address the complexity of the work needed
to achieve HRO status may overwhelm the organization. The past history of how quality
improvements were made in the healthcare organization can limit future improvements.

114 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

For instance, a nurse is preparing an insulin injection at the medication station. When
reaching for an insulin syringe, the nurse discovers that insulin and tuberculin syringes
are mixed together in the same container. Using the wrong syringe would result in a
medication error. The last time a medication error was made on the unit, the nurse was
suspended for 3 days. Due to the punishment associated with the last medication error,
the nurse decides to separate the insulin and tuberculin syringes into two containers
rather than reporting the near miss. In this example, the organization does not have the
opportunity to examine why the two syringes were mixed together in the same container
since the nurse fixed the problem. Without knowledge of the near miss, no actions can be
taken to prevent the problem from occurring again.

Workplace Intimidation and Disruptive Behavior

Workplace intimidation and making others feel fearful, timid, orinferior destroys the
trust environment that is essential for a culture of high reliability. Workplace intimi-
dation is created by disruptive behaviors or behaviors that do not support a culture
that makes safety a priority. A culture of safety is a necessary element of an HRO.
Workplace intimidation behaviors such as refusing to answer a question, not answer-
ing a page, using nonverbal gestures of disapproval, and raising one’s voice need to be
eliminated in an HRO to build the critical component of trust. Accepting disrespectful
or disruptive behavior from any interprofessional team member is a potential threat to
quality and safety for an organization. Committed leaders must recognize and manage
this unwanted behavior to create a culture or safety.

Interprofessional Complexity

The complexity of the healthcare environment creates challenges for the HRO. The
safety of patient care relies on effective coordination and communication among the
diverse interprofessional staff who provide healthcare. Different members of the inter-
professional team come from very diverse educational preparation and may use dif-
ferent terminology. This diversity creates a challenge in making decisions required for
safe care. The complex dependency of healthcare processes requires coordination of
efforts across the healthcare continuum. For example, the coordination of interprofes-
sional healthcare processes is essential for a safe patient transition when preparing a
patient to be discharged from the acute care setting to the home environment. Extensive
coordination and clear communication among the entire healthcare team facilitates the
provision of posthospital services the patient may require, the prescriptions needed,
follow-up appointments, patient and family understanding of care instructions, and
appropriate transportation.

Hierarchies

Challenges inherent in healthcare hierarchies was discussed earlier in this chapter.
Traditionally, the physician was the leader in the provision of healthcare, and the hier-
archical roles of physicians, nurses, and organizational leadership create a challenge
to implementing the HRO principles. In contrast, the HRO values the perspective of
all healthcare team members. In doing so, the HRO works toward eliminating power
hierarchies and allowing for open communication among the interprofessional health-
care team to ensure safety.

4 QUALITY AND SAFETY IN HIGH-RELIABILITY ORGANIZATIONS • 115

Information Systems

The use of health information systems for the documentation of care and the gather-
ing of quality and safety information is essential. Additionally, healthcare informa-
tion systems provide a means for reporting errors and near misses. The lack of health
information systems can impede progress to an HRO. Healthcare organizations may
be challenged with devoting scarce resources to implement information systems that
require significant capital expense and ongoing maintenance costs.

INTERNAL STRUCTURES AND ROLES TO SUPPORT
AN HRO

A strong infrastructure is needed to support the goals and strategies of the organi-
zation’s quest toward becoming an HRO. The governing body, typically the board
of directors, must set the priority for quality and safety. Implementing quality and
safety initiatives requires an executive team that is committed to leading an orga-
nization on the journey to high reliability. Nurses, physicians, and all members of
the interprofessional team must be engaged at all levels of the quality and safety
infrastructure.

The CEO sets the tone when creating an HRO. The CEO oversees safety and qual-
ity efforts within the organization. Often, the CEO chairs an interprofessional safety
and quality committee. Committee membership includes a patient safety officer; phy-
sicians; nurses; pharmacists; staff from risk management, quality, patient experience,
and infection control; and a community member. Multiple committees, defined in
Table 4.2, exist to support the overall work of the board of directors and the safety and
quality committee.

In addition to the committees discussed, certain departments and key positions
in an organization support the infrastructure of an HRO. Supporting departments can
perform multiple functions. They may ensure public reporting of quality and safety
data, identify external benchmarks, facilitate process improvements, participate in
external learning collaboratives, improve clinical documentation, detect and prevent
infections, expedite peer review, oversee regulatory and accreditation compliance,
provide risk management, and improve the customer experience.

Key positions in an organization also support the journey to high reliability. Not
all healthcare organizations will have every position described in the following, but
most will have a majority of the positions. A patient safety officer is the quality and
safety leader at the executive level. The patient safety officer provides leadership for
error prevention, error identification and reporting, and reduction of the severity of
harm. The role of the patient safety officer closely aligns to the role of risk manager.
The risk manager is responsible for protecting the assets of the organization by under-
taking activities to identify, evaluate, and reduce the likelihood of patient injury and
the risk of loss to the organization.

In the journey to high reliability, several new roles have emerged or expanded
in healthcare organizations. A human factors engineer (HFE) may be engaged in
an HRO as a support professional. Human factor engineering is an interprofes-
sional approach that looks at the safety and efficiency of work systems. The HFE
examines how people, policies, technology, and work structures interact to improve
quality, safety, efficiency, and reliability of healthcare provision. The HFE can also
function as educator and project consultant for clinical effectiveness and quality
improvement teams. A quality analyst can also function as an expert in the process

116 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

improvement methodologies and tools. A clinical documentation expert assesses
and supports documentation processes to ensure that they accurately reflect the
patient’s condition and the level of service required to meet the patient’s care need.

TABLE 4.2 COMMITTEES THAT SUPPORT A JOURNEY TOWARD HIGH RELIABILITY

Board Quality Committee Provides oversight for patient safety and quality of
care, including physicians and other professional
credentialing and privileging. In some hospitals, the
board of trustees may perform these functions.

Medical Staff Executive
Committee

Supports medical staff processes and clinical quality
improvement.

Credentials Committee Ensures that qualified, competent providers practice
in the organization.

Hospital Safety and Quality
Committee

Provides leadership to implement the safety and
quality plan.

Infection Control Committee Provides leadership for the infection prevention and
control program.

Utilization Review Committee Oversees appropriate utilization of care and services
provided by the hospital; ensures the management
of the appropriate admission status of the patient
(inpatient, outpatient, or observation) based on the
severity of the patient’s illness.

Medical Staff Quality
Committee

Conducts retrospective reviews of patient care (peer
review), focused professional practice evaluation,
and ongoing professional practice evaluation to
identify opportunities for improvement and to share
what was learned with other physicians, licensed
independent practitioners, and advanced practice
clinicians.

Safety Event Review
Committee

Reviews and classifies safety events and
commissions root cause analyses.

Nursing Quality Committee Fosters nursing and interprofessional performance
improvement activities.

Nursing Peer Review
Committee

Conducts retrospective reviews of nursing patient
care, focused professional practice evaluation, and
ongoing professional practice evaluation to identify
opportunities for improvement and to share what
was learned with other clinicians.

Pharmacy and Therapeutics
Committee

Provides leadership for safe medication processes.
May include a subcommittee focused on antibiotic
stewardship.

Environment of Care
Committee

Provides leadership for the ongoing evaluation and
improvement of the environment of care safety
management program.

Ethics Committee Provides support for ethical dilemmas that present
themselves in clinical care.

Institutional Review Board
Committee

Responsible for ensuring that all research practices
are safe and follow standard guidelines for the
conduct of research.

Workplace Safety Committee Reviews workplace injuries and sets goals and
strategies for improving workplace safety.

4 QUALITY AND SAFETY IN HIGH-RELIABILITY ORGANIZATIONS • 117

A patient experience expert provides leadership to ensure that the patient receives
respectful and coordinated care and to facilitate a process to address complaints
that may arise when failure to meet patient’s healthcare expectations occur.

As healthcare increases its focus on coordinated healthcare across multiple
providers and settings, many organizations are expanding care management and
social services to encompass transitional care for patients. This community case
management role focuses on ensuring safe patient transitions to home or to another
healthcare service. An initial primary focus is on the transition from hospital to
home for patients with chronic disease and end-of-life issues to ensure that health-
care is provided seamlessly. Transitional care nurses help coordinate care between
transitions to different care settings such as hospital to home healthcare and assist
patients to navigate the complex healthcare system. A well-defined organization
infrastructure that promotes teamwork and communication supports the transi-
tion to an HRO.

EXTERNAL INFLUENCES FOR CHANGE AND HRO
RESOURCES

Increasingly, the government is mandating that hospitals publicly report safety, qual-
ity, and financial indicators. This transparency is designed to help the consumer make
informed choices about selecting healthcare providers. Transparency holds healthcare
providers and organizations accountable for quality care. In other purchase transac-
tions, consumers can easily obtain information about cost and value to make informed
purchases. Healthcare is now being asked to follow the same practice of transparency.
Public awareness of medical errors, poor quality outcomes, and perceived low value
are driving changes in healthcare.

Centers for Medicare and Medicaid Services

Healthcare costs have escalated along with poor quality of care and patient outcomes,
healthcare errors, and waste. Historically, organizations were rewarded for the vol-
ume of healthcare services delivered instead of for their achievement of high-quality
and safety outcomes. For example, a hospital used to be reimbursed for the number
of appendectomies performed regardless of the outcome. As previously described,
safety, quality, and experience outcomes now affect hospital reimbursement. In addi-
tion, safety, quality, and patient experience data are posted on the CMS website (www.
medicare.gov/hospitalcompare/search.html). Last, the Centers for Medicare and
Medicaid Innovation was created as part of the Affordable Care Act to enhance the
quality of healthcare and reduce costs through innovative approaches to healthcare
delivery.

Leapfrog

Leapfrog, a business consortium, is a voluntary reporting agency that collects and
publishes quality information. The Leapfrog website allows insurance companies
and the public to access hospital ratings and use the information to make informed
healthcare decisions. The Leapfrog consortium works on behalf of the public and

118 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

employers to inform Americans about the performance of hospitals on quality
measures. The Leapfrog group promotes full disclosure of hospital performance
information and helps provide employers with information to provide the best health-
care benefits to employees.

Accreditation Agencies

Several accrediting agencies for hospitals address patient safety. These agencies
include TJC, Healthcare Facilities Accreditation Program (HFAP), and Det Norske
Veritas Healthcare, Inc. (DNV, n.d.; Meldi, Rhoades, & Gippe, 2009).

The mission of TJC is to continuously improve healthcare for the public, in col-
laboration with other stakeholders, by evaluating healthcare organizations and inspir-
ing them to excel in providing safe and effective care of the highest quality and value
(TJC, 2017). TJC uses the Donabedian conceptual framework of structure, process, and
outcomes to assess an organization. Using this framework, TJC (2017, March 1) set 11
expectations for leadership in developing a safety culture as follows:

1. Create a transparent, nonpunitive approach to reporting and learning from
adverse events, close calls, and unsafe conditions.

2. Establish clear, just, and transparent risk-based processes for recognizing and sep-
arating human error and error arising from poorly designed systems from unsafe
or reckless actions that are blameworthy.

3. Adopt and model appropriate behaviors and champion efforts to eradicate intimi-
dating behaviors.

4. Establish, enforce, and communicate to all team members the policies that support
safety culture and the reporting of adverse events, close calls, and unsafe conditions.

5. Recognize team members who report adverse events and close calls, who identify
unsafe conditions, or have good suggestions for safety improvements.

6. Establish an organizational baseline measure on safety culture performance using
the AHRQ hospital survey on patient safety culture or another tool, such as the
safety attitudes questionnaire.

7. Analyze safety culture survey results from across the organization to find oppor-
tunities for quality and safety improvement.

8. Develop and implement unit-based quality and safety improvement initiatives
designed to improve the culture of safety.

9. Embed safety culture team training into quality improvement projects and orga-
nizational processes to strengthen safety systems.

10. Proactively assess system strength and vulnerabilities and prioritize them for
enhancement or improvement.

11. Repeat organizational assessment of safety culture every 18 to 24 months to
review progress and sustain improvement.

HFAP was originally created in 1945 to conduct an objective review of services
provided by osteopathic hospitals. In 1965, HFAP received authority from the CMS to
provide accreditation to hospitals, ambulatory care/surgical facilities, mental health
facilities, physical rehabilitation facilities, clinical laboratories, and critical access hos-
pitals. HFAP has adopted the 34 Safe Practices set forth by the National Quality Forum
(NQF) in 2009 (HFAP, 2017).

DNV is dedicated to empowering quality and patient safety through an efficient
and outcomes-based accreditation program. DNV received authority from the CMS to

4 QUALITY AND SAFETY IN HIGH-RELIABILITY ORGANIZATIONS • 119

provide accreditation to hospitals in 2008, and has accredited nearly 500 hospitals of
all sizes and in every region of the United States. They integrate the CMS Conditions
of Participation with the ISO 9001 Quality Management Program. The ISO 9001 qual-
ity system is a structured way of delivering a better service or product, supported
by detailed procedures such as work instructions, quality manuals, and written qual-
ity policies to provide all employees with detailed, understandable, and workable
instructions that define both expectations and actions to achieve the stated quality
goals. DNV’s goal is to enable a broader culture change toward high performance and
continual improvement by combining the mandatory CMS evaluation with a quality
management system into one seamless program.

State Requirements

Along with the quality and safety measures publicly reported by the CMS, many states
are now requiring some form of mandatory reporting of safety and quality indicators
and specific adverse events.

Public Recognition of Quality Achievements

In the race to achieve competitive advantages for patient safety and quality, health-
care organizations are seeking recognitions that set them apart from other healthcare
organizations. The Baldrige Award recognizes organizations that have improved
and sustained quality results. The purpose of the Baldrige Award in healthcare is
to challenge organizations to improve their effectiveness of care and healthcare out-
comes to pursue excellence, which moves organizations toward becoming an HRO.
The Baldrige framework embraces integration among leadership, strategy, custom-
ers, workforce, operations, and results. The Baldrige framework is built on core val-
ues and concepts and requires measurement, analysis, and knowledge management
(NIST, 2016).

Designation by the American Nurse’s Credentialing Center (ANCC) as a Magnet®
organization denotes nursing excellence and is factored into payer reimbursement and
recognition (ANCC, 2013). The components of the Magnet Recognition Program®,
discussed in Chapter 1, are congruent with the HRO concepts. The Magnet® com-
ponents include Transformational Leadership; Structural Empowerment; Exemplary
Professional Practice; New Knowledge, Innovations, and Improvements; and Empirical
Outcomes. The original forces of Magnetism emphasized structure and process. The
current Magnet Model recognizes that an excellent infrastructure must result in posi-
tive outcomes in order to create a culture of excellence and innovation. Safety is a main
component of a culture of excellence.

The Transformational Leadership component of the Magnet Model requires
strong advocacy and support for staff and patients by all nursing leaders. In a Magnet-
designated hospital, the CNO is an active leader in creating an HRO by establish-
ing strategic goals for quality and safety in conjunction with the hospital’s executive
team. These strategic goals support the organization’s commitment to zero major
quality failures. For example, one source of evidence related to Transformational
Leadership calls for nurse leaders and clinical nurses to advocate for resources to
support nursing unit and organizational goals. The Structural Empowerment com-
ponent of Magnet addresses the need to create structures and processes that allow

120 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

nurses to practice safely and effectively. For example, one source of evidence related
to Structural Empowerment calls for clinical nurse involvement in interprofessional
decision-making groups at the organizational level. In total, five of the 11 Structural
Empowerment sources of evidence address the culture of safety for patients and
nurses. Both the Transformational Leadership and Structural Empowerment compo-
nents of Magnet require the active engagement of nurses.

The Exemplary Professional Practice component of Magnet indicates that “achieve-
ment of exemplary professional practice is grounded in a culture of safety, quality
monitoring, and quality improvement” (ANCC, 2013, p. 42). Many of the Exemplary
Professional Practice sources of evidence require documentation of safe nursing prac-
tices. For example, Magnet acute care organizations with ambulatory services are
required to report on these six nurse-sensitive clinical indicators: patient falls with
injury, hospital-acquired pressure ulcers, central line-associated bloodstream infection,
CAUTI, one indicator from the Core Measures Set, and one indicator from primary or
specialty outpatient services. The performance on each of these indicators must exceed
the mean or median value on the majority of units the majority of the time to meet
Magnet standards. The New Knowledge, Innovations, and Improvements component
of Magnet requires nurses to use evidence and innovation for safe, high quality care.
Last, the Empirical Outcomes component of Magnet requires the organization to con-
tinually assess and monitor a variety of indicators for nursing leadership and clinical
practice. Sustained quality performance on empirical outcomes will move an organi-
zation on the journey to becoming an HRO.

Additional Resources for Organizations Striving for High Reliability

A patient safety organization (PSO) is a group, institution or association that improves
patient care by reducing errors. PSOs exist to allow organizations to learn from their
own safety events and the safety events of others. The Patient Safety and Quality
Improvement Act of 2005 (Public Law 109–41), signed into law on July 29, 2005, was
enacted in response to growing concern about patient safety in the United States and
the IOM’s (1999) report To Err Is Human. A healthcare provider can obtain the confi-
dentiality and privilege protections of the act by working with a federally listed PSO.

A nurse works for an organization that has achieved Magnet designation. The
nurse is a member of the Quality and Safety Unit Practice Council. As a member
of the Council, the nurse is assigned the task of educating nursing and other peers
on how the Magnet designation supports and helps the organization become an
HRO. Complete a web literature search on the Magnet components and correlate
the key Magnet principles to the HRO concepts.

1. How do the Magnet components support the organizational requirements for high
reliability?

2. How do the Magnet components align with the HRO process concepts?
3. How do the Magnet components support a culture of safety?

CASE STUDY 4.2

4 QUALITY AND SAFETY IN HIGH-RELIABILITY ORGANIZATIONS • 121

The law provides confidentiality protections and privilege protections, which means
the information cannot be included in a law suit. A complete list of federally approved
PSOs may be found on the AHRQ website (www.pso.ahrq.gov/listed).

The AHRQ’s mission is to produce evidence to make healthcare safer, higher
in quality, more accessible, equitable, and affordable, and to work with the U.S.
Department of Health and Human Services and with other partners to make sure that
research findings are understood and used. AHRQ creates materials to teach and train
healthcare systems and professionals to put the results of research into practice and
funds a variety of initiatives. In addition to the AHRQ initiatives already discussed in
this chapter, successful initiatives include the following:

• Re-Engineered Discharge (RED)—a structured protocol and suite of implementa-
tion tools that help hospitals rework their discharge processes to reduce readmis-
sions by determining patients’ needs and carefully designing and communicating
discharge plans.

• The Comprehensive Unit-based Safety Program (CUSP)—a highly effective
method of preventing healthcare-associated infections (HAIs) by combining
improvement in safety culture, teamwork, and communication.

• EvidenceNOW, an initiative aligned with Million Hearts®—provides clinical
practice support to over 5,000 primary care physicians with the goal of improving
the heart health of millions of patients and improving the capacity of the practices
to incorporate new research findings and information into practice.

• AHRQ’s Healthcare Cost and Utilization Project—helps highlight the opioid over-
dose epidemic and contributed to the Department of Health and Human Services’
launch of a major multipronged initiative to reduce opioid abuse.

The work of the IHI began in the late 1980s as part of the National Demonstration
Project on Quality Improvement in Health Care to redesign healthcare into a sys-
tem without errors, waste, delay, and unsustainable costs. IHI uses the science of
improvement approach to work with health systems, countries, and other orga-
nizations on improving quality, safety, and value in healthcare. The approach is
characterized by the combination of expert subject knowledge with improvement
methods and tools. It is interprofessional, drawing on clinical science, systems the-
ory, psychology, statistics, and other fields.

IHI’s methodology traces back to W. Edwards Deming (1900–1993), who taught
that by adhering to certain principles of management, organizations can increase
quality and simultaneously reduce costs. Based on Deming’s work, the IHI Model for
Improvement asks three questions as follows:

1. What are we trying to accomplish?
2. How will we know that a change is an improvement?
3. What changes can we make that will result in improvement?

The Model then employs Plan-Do-Study-Act (PDSA) cycles for small, rapid-cycle tests of
change. IHI uses the Model for Improvement in all of its improvement efforts (IHI, 2017a).

The vision of the National Patient Safety Foundation (NPSF, 2017) is to create a
world where patients and those who care for them are free from harm. A central voice
for patient safety since 1997, NPSF partners with patients and families, the health-
care community, and key stakeholders to advance patient safety and healthcare work-
force safety and disseminate strategies to prevent harm. Committed to a collaborative
approach in all that it does, the NPSF offers a portfolio of programs targeted to diverse
stakeholders across the healthcare industry. The American Society of Professionals in

122 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

Patient Safety (ASPPS) is part of NPSF. It provides education and oversees profes-
sional certification (ASPPS, 2017).

The Institute for Safe Medication Practices (ISMP) is the nation’s only nonprofit
organization devoted entirely to medication error prevention and safe medication use.
It is respected worldwide as a resource for impartial, timely, and accurate medication
safety information. ISMP’s medication error prevention efforts began in 1975. ISMP
began a voluntary practitioner error-reporting program to learn about errors happen-
ing across the nation, understand their causes, and share “lessons learned” with the
healthcare community. Today, ISMP’s initiatives, which are built upon a nonpunitive
approach and system-based solutions, fall into five key areas: knowledge, analysis,
education, cooperation, and communication (ISMP, 2017).

ISMP is also responsible for reviewing all medication error reports submitted by
healthcare facilities to the Commonwealth of Pennsylvania Patient Safety Authority.
Each year, ISMP’s national Medication Errors Reporting Program (MERP) receives hun-
dreds of error reports from healthcare professionals. In addition, ISMP’s wholly owned
corporate subsidiary, Med-ERRS (Medical Error Recognition and Revision Strategies),
works directly and confidentially with the pharmaceutical industry to prevent errors
that stem from confusing or misleading naming, labeling, packaging, and device design.

The mission of NQF is to improve the quality of healthcare. Patient safety
is central to achieving this mission. Of the over 600 NQF-endorsed quality mea-
sures, approximately 100 are patient-safety focused. NQF has also endorsed 34
Safe Practices for Better Healthcare and 28 Serious Reportable Events (NQF, 2017).
Despite these achievements, there are still significant gaps in the measurement of
patient safety. By convening panels and other educational forums, NQF works with
quality measure developers and others in healthcare to help understand measure-
ment gaps and encourage strategies to fill them. A list of 28 adverse events, also
called never events because they should never occur in healthcare, is grouped into
six categories: surgical, product or device related, patient protection, care manage-
ment, environmental, radiologic, and potential criminal events (www.qualityfo-
rum.org/topics/sres/serious_reportable_events.aspx).

Medical Product Safety Network (MedSun)

The Medical Product Safety Network (MedSun) is an adverse event reporting program
launched in 2002 by the U.S. Food and Drug Administration’s Center for Devices and
Radiological Health (FDA, 2017). The primary goal for MedSun is to work collaboratively
with the clinical community to identify, understand, and solve problems with the use of
medical devices. Once a problem is identified, MedSun clarifies the problem and shares
lessons learned with the clinical community and the public, without facility and patient
identification, so that clinicians nationwide may take necessary preventive actions.

The Safe Medical Devices Act defines device user facilities as hospitals, nursing
homes, and outpatient treatment and diagnostic centers, and requires them to report
medical device problems that result in serious illness, injury, or death. MedSun par-
ticipants are also highly encouraged to voluntarily report problems with devices, such
as “close-calls,” potential for harm, and other safety concerns. By monitoring reports
about problems and concerns before a more serious event occurs, the FDA, manufac-
turers, and clinicians work together proactively to prevent serious injuries and death.
Human Factor Engineers can play a key role here, as they examine how clinicians,
products, policies, and the work environment interact to affect safety.

Healthcare organizations are recognized for reporting events that result in
manufacturing changes. For example, Nancy is a nurse in the ICU. She received

4 QUALITY AND SAFETY IN HIGH-RELIABILITY ORGANIZATIONS • 123

a patient from surgery who was wearing a purple armband, which designates a
Do Not Resuscitate (DNR) status in Nancy’s hospital. There was no indication of
a DNR order for this patient, so Nancy asked the patient about the purple band.
The patient explained that she received the purple band at an outpatient surgical
center when her port was implanted. It was part of the port kit provided by the
manufacturer, and staff suggested that the patient wear the band to remind health-
care providers of her port. Nancy then explained the meaning of the band at most
hospitals. When the patient heard this, she stated her desire to be resuscitated,
Nancy asked permission to remove the band. The patient granted this permission
and Nancy reported the event as a near miss. Nancy received a Good Catch award
for averting harm. In addition, the organization reported the event to MedSun.
MedSun worked with the manufacturing company to change their practices and
the company stopped including the purple band in their port kits. This is an exam-
ple of high reliability at its finest—focusing on improving patient safety internally
and nationally.

The journey toward high reliability is complex and involves every aspect of an
organization. Errors in healthcare cause harm to patients. Healthcare organizations
can apply what has been learned in other safety-focused industries to improve patient
safety. Nurses are in a strong position to advocate for patient safety and lead interpro-
fessional efforts to achieve high reliability. While barriers to HRO exist, they can be
overcome with the use of internal and external resources.

KEY CONCEPTS

• An HRO targets near-zero rates of failure.
• Characteristics that differentiate healthcare HROs from other healthcare organiza-

tions are preoccupation with failure, reluctance to simplify, sensitivity to operations,
commitment to resilience, and deference to expertise.

• Being a HRO affects a healthcare organization’s safety, quality, patient experience,
and financial performance.

• Healthcare has learned a great deal about high reliability from other industries, such
as commercial aviation and nuclear power.

• To achieve high reliability, an organization must have strong leadership commit-
ment, an established culture of safety, and a well-developed quality improvement
program.

• A fair and just culture minimizes blame and punishment and creates a learning envi-
ronment where errors are reported so that system problems can be corrected.

• The nurse is responsible for implementing internal behaviors and communication
techniques and working effectively in an interprofessional team in a healthcare HRO.

• Organizational culture can be assessed with valid and reliable tools to support a
journey toward becoming an HRO.

• Barriers to achieving high reliability may include culture, history and traditions,
workplace intimidation and disruptive behavior, interprofessional complexity, hier-
archies, and information systems.

• A healthcare organization’s infrastructure must provide support to achieve high
reliability.

124 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

• Many organizations influence a healthcare organization’s decision to become an
HRO and provide support for the journey toward high reliability.

• The components of the Magnet Recognition Program are congruent with HRO concepts.

KEY TERMS

Adverse event or serious safety event
AHRQ
Authority gradient
Baldrige Award
Comorbidities
Cross-monitoring
Culture of safety
Daily safety huddle
Error
Fair and just culture
Financial performance
FMEA
Hierarchy
HRO
IHI
ISMP
Knowledge-based performance

Magnet
Mutual support
Near miss safety event
NQF
Organizational culture
Patient experience
Precursor safety event
PSO
Quality
RCA
Reliability
Rule-based performance
Safety
Sentinel event
Skill-based performance
Transparency
Work arounds

REVIEW QUESTIONS

1. Which of the following recommendations was not made by the Institute of
Medicine’s publication To Err Is Human?

A. Identify and learn from errors.
B. Avoid talking about errors.
C. Improve safety.
D. Ensure safe practices at the delivery level.

2. Which statements about an HRO are false? Select all that apply.

A. HROs avoid discussing failures.
B. HROs explore a variety of reasons for errors and are reluctant to simplify

explanations.
C. HROs are aware of the many factors that influence the care environment.
D. HROs understand that decisions should be made by the highest ranking

official.
E. HROs know that when small things go wrong it is often a sign of a larger

problem.

3. Errors occur when there is a deviation from generally acceptable performance
standards. Which of the following is not an example of a generally acceptable per-
formance standard?

A. Professional practice standard.
B. Article published in the Wall Street Journal.

4 QUALITY AND SAFETY IN HIGH-RELIABILITY ORGANIZATIONS • 125

C. Evidence-based policy.
D. Evidence-based order set.

4. High reliability affects the entire organization. Which of the following statements
is false?

A. Quality often improves in HRO organizations.
B. An HRO improves patient and staff safety.
C. Enhanced communication and reliability helps to increase patient satisfaction

in HROs.
D. Financial performance is negatively impacted in HROs.

5. Healthcare can learn about high reliability from a variety of other industries.
Which of the following statements is false?

A. Commercial aviation found that the most common cause of error was mechani-
cal failures.

B. The Institute of Nuclear Power Operations believes that trust and respect are
needed in an HRO.

C. Human beings can make skill-based, rule-based, and knowledge-based errors.
D. Commercial Aviation embraced CRM training programs in an effort to enhance

communication in the cockpit.

6. Leadership plays an important role in creating an HRO. Which of the following
statements demonstrates the best understanding of the role of leadership?

A. Leaders are accountable for the provision of effective and efficient care while
protecting the safety of patients, employees, and visitors.

B. Leaders must identify system problems and ask employees to fix them.
C. While fostering a learning environment, leaders must never discipline employ-

ees for their behaviors.
D. Leaders may rely solely on technology to build and reinforce accountability.

7. A nurse is asked how quality, safety, and performance improvement are addressed
in an HRO. Which response demonstrates the best understanding?

A. “We have an interprofessional committee on our unit that looks at patient
outcomes, practice issues, and most recently, the number of falls on our unit.
Together, we figure out the best way to fix the problem and suggest changes.”

B. “A couple of nurses got together last night to look at the number of falls on our
unit. We are concerned about the problem and think there is a better way to do it.”

C. “I saw an article about falls on a unit like ours. I took the article to work to
show my unit director but she said the solution isn’t feasible on our unit.”

D. “Our fall rates are so high that the physical therapist formed a committee to
address the issue and came back to the nursing staff with some recommenda-
tions for changes in our care delivery.”

8. Which of the following methods are helpful for assessing the culture of an HRO?
Select all that apply.

A. Observe the behaviors of employees when they think no one is watch-
ing to determine if they are adhering to the policies and expectations of the
organization.

B. Review safety event reports, including near miss, precursor, and serious safety
events.

126 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

C. Use a standard tool to assess the patient safety of the organization.
D. Assume the culture exists if process improvement activities are underway.

9. Many barriers keep healthcare organizations from becoming HROs. Which of the
following statements is false?

A. Culture, history, and tradition may be a barrier to becoming an HRO.
B. Information systems always serve as a barrier to creating an HRO.
C. Workplace intimidation and disruptive behavior cannot be tolerated in an HRO.
D. The hierarchical roles of physicians, nurses, and organizational leadership cre-

ate a challenge to implementing HRO principles.

10. Which of the following external organizations strongly influence hospitals to
change to become HROs? Select all that apply.

A. CMS
B. Magnet recognition by the American Nurses Credentialing Center
C. The National Labor Relations Board and Office of Human Subjects Protection
D. Accreditation agencies, such as TJC and DNV
E. Consumer groups, such as Leapfrog
F. Vendors of EHRs

REVIEW ACTIVITIES

1. During one of your clinical days, ask nurses to describe the process in place to
report an error in their hospital and what happens when an error is reported. Ask
the nurses if they have ever reported an error. Based on what you have learned, is
the reporting method focused on blame or learning?

2. Leaders are responsible for creating a culture of high reliability. Review the roles of
the leader as outlined in this chapter. During your next clinical rotation, assess the
culture of the healthcare organization. Is it obvious that the leaders are commit-
ted to safety? Are the leaders visible? Does the healthcare organization provide a
learning environment? Are process improvements underway? Is technology used
to enhance safety?

3. Review the chapter content related to Safety Stories. Why is it important to share
Safety Stories? How does it strengthen the HRO culture and a healthcare organiza-
tion? During your next clinical day, identify a Safety Story and share it with your
classmates.

4. Review the chapter content related to the Science of Human Error. Why is it impor-
tant to know if the error is skill-based, rule-based, or knowledge-based? What
types of errors have you made in your personal or professional life? What types of
tools would be helpful in preventing these errors?

5. Review the chapter content related to the SBAR and I PASS the BATON commu-
nication tools. The next time you are providing care, try using one of these tools
in your handoff to another provider. How effective was the tool? Did the tool help
you to organize your thoughts more concisely? Did it prompt you to share the
most pertinent information?

6. Review the external forces that influence the need for change in quality and safety.
How does transparency influence quality and safety? What resources are available
to assist a healthcare organization on the road to high reliability?

4 QUALITY AND SAFETY IN HIGH-RELIABILITY ORGANIZATIONS • 127

CRITICAL DISCUSSION POINTS

1. Consider a recent clinical experience. What characteristics of an HRO were vis-
ible? Describe what you felt met the explanation in the text of characteristics
of HROs.

2. Interview a nurse about the error reporting process in his or her current practice
setting. Is it anonymous? Does it include reporting near misses or just errors? Ask
if the nurse feels comfortable reporting his or her own or other’s errors. Why or
why not?

3. What would you consider a priority for an organization that is working towards a
culture of safety? Explain why you selected the priority.

EXPLORING THE WEB

1. Go to the website for the AHRQ (www.ahrq.gov). Review one of the patient safety
survey tools. How would you complete the survey for the site of your most recent
clinical rotation?

2. Go to the website for the CMS Hospital Compare at www.medicare.gov/hospital
compare/search.html. Review the ratings for several hospitals close to your zip code.

3. Go to TJC website at www.jointcommission.org. Review their vision for health-
care. Review the most recent NPSGs.

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